MN Hockey Screening Form
The BHC has recently posted an On Line MN Hockey (MH) Confidential Screening and Consent Form. This form is REQUIRED for all Board Members, Coaches, Assistant Coaches, and Managers to fill out EACH season.
We are asking all potential Head and Assistant Coaches to fill out the Application at their earliest convenience. Please return the completed form to BIC - attention BHC Registrar ALONG with a current copy of your coaches card - front and back.
Paper copies will also be available at BIC
MN Hockey Web Site Forms {Click here}
.pdf version of Screening Form {Click here}
Here is a text copy:{use the .pdf version if at all possible}
FORM MUST BE FILLED OUT COMPLETELY WHERE WILL YOU COACH OR REFEREE?
OR APPLICANT SHALL BE DISQUALIFIED Hockey Association ___________________________MH District__________
APPLICANT MUST PROVIDE SSN (Do not abbreviate name)
MINNESOTA HOCKEY (MH) CONFIDENTIAL SCREENING AND CONSENT FORM
Applicant’s Full Name (please print)
First Middle Last
Maiden, Alias or Former Name (please print) Telephone number ( )
Birth Date (MM/DD/YYYY) ____/____/______ Gender: M ___ F ___ Social Security Number _____-____-______
( REQUIRED)
Current Address
Street & No. City State Zip
Prior Address if less ______________________________________________________________________________________________
than 10 Years in MN Street & No. City State Yrs. of Residence
Attach separate sheet if additional space is needed.
Email address for hockey contact ________________________________@___________________________________________________
What positions do you anticipate holding in the next 12 months? Mark all that apply.
Coach ______ Manager _______ MH Officer/Board/Committee Member ________
Local or District Officer/Board/Committee Member _____ On-Ice Official ________
ARE YOU A 1ST YEAR COACH/OFFICIAL? YES __ NO __
DID YOU COACH WITH THE SAME ASSOCIATION LAST YEAR? YES __ NO __
PLEASE NOTE THAT INFORMATION OBTAINED WITH THIS CONSENT FORM RELATING TO BACKGROUND CHECK CRIMES (AS
DEFINED ON THE REVERSE SIDE) OR CRIMES INVOLVING THEFT OR DISHONESTY MAY BE DISCLOSED BY MINNESOTA HOCKEY
TO ITS AFFILIATE ORGANIZATIONS AND MAY BE USED TO DETERMINE ELIGIBILITY TO PARTICIPATE IN MINNESOTA HOCKEY
ACTIVITIES ACCORDING TO MINNESOTA HOCKEY BYLAWS AND POLICY.
1 . Do you authorize Minnesota Hockey or related organizations to obtain criminal background check
information about you from relevant law enforcement agencies or other screening services? Failure to
do so will disqualify you from participation in activities of MH or organizations associated with MH.
2 . Have you been convicted of any of the crimes referenced in Minnesota Statutes Chapter 299C, (see list of
crimes on reverse side) regardless of where they may have occurred or under which laws they may have
been charged or prosecuted? (If you have been convicted, please attach a description of the crime
and the particulars of the conviction.) READ AND ANSWER THIS QUESTION CAREFULLY!
3 . a) Have you ever been held liable for civil penalties or damages involving sexual or physical abuse of
children?
b ) Have you ever been subject to any court order involving sexual abuse or physical abuse of a minor,
including, but not limited to, a domestic order for protection?
c ) Have you ever had your parental rights terminated for reasons involving sexual or physical abuse of
children?
If your answer is “YES” to 3 a), b) or c), please attach a description of the facts and the particulars of the
case.
4 . Has any of the information entered on this form changed since your last application?
5 . Do you authorize Minnesota Hockey to obtain updated criminal background check information about you
for so long as you are actively participating in activities of MH or organizations associated with MH? Failure to
do so will disqualify you from participation.
1. YES __ NO __
2. YES __ NO __
3.a YES __ NO __
3.b YES __ NO __
3.c YES __ NO __
4. YES __ NO __
5. YES __ NO __
BEFORE SIGNING BELOW, BE SURE THAT YOU HAVE CHECKED YES OR NO TO EVERY QUESTION ABOVE AND COMPLETED ALL
REQUIRED INFORMATION.
Signature of Applicant ______________________________ Today’s Date _________________________________
Signature of Witness _______________________________ Today’s Date _________________________________
Revised 6/29/06
DO NOT WRITE IN THIS SPACE FORM______ BCA+______ 4A______ 4B______
COMMITTEE______ APPEAL_____
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