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Disclosure Form

Last Name ___________________	First Name ________________	Ml _____
Street Address ________________________	City	State
_____ Zip	Home Phone ( )	Work Phone
Social Security Number	Passport #	Date of Birth MO___ DAY___ YR___.

Employer_	Work Phone(______________________	Driver's License #________________
State_____	Country_____________	Expiration Date____________________

[ ] Male	[ ] Female	Coaching License_______________
Referee Grade___________	Previous residence(s) last 5 years (use back of form if necessary)	City State_________

Background in work with youth: Position__________________________________________	Years__________
Experience in soccer: Position_____________________________________________	Years__________

Have you ever been convicted of a crime of violence or a crime against a person? Yes_________ No_________

Have you ever been convicted of a felony? Yes________ No________

Have you ever been subject to any court order involving sexual, physical or verbal abuse, including, but not limited to, a domestic or protection order? Yes_________ No_________

Have you ever been adjudged liable for civil penalties or damages involving sexual, physical or verbal abuse? Yes_________ No_________

Do you have a history of complaints of sexual, physical or verbal abuse? Yes_________ No_________

Have you ever resigned, been terminated or been asked to resign from any position paid or unpaid, due to complaint(s) of sexual, physical or verbal abuse? Yes_________ No_________

Have you used an illegal substance in the past 10 years? Yes________ No________

Do you have a conviction for the use and/or sale of an illegal substance? Yes_________ No_________

Please explain each yes answer in detail. Use back of form or additional pages as necessary.

With my signature, I agree that:

1. In applying for a position, the information which I have furnished on this form is subject to verification, which may include a criminal history check requiring fingerprints.

2. It is the intent of ISAI, Inc and RAHF to deny certification to any person who has been convicted of a crime of violence or crime against a person or a felony.

3. As a coach and/or a program administrator, I will abide by Club, League, RAHF and FIFA bylaws, rules, regulations, policies and procedures. I further agree that I am accountable for knowing, understanding and following these regulations.

4. The Disclosure Statement must be updated at least every two (2) years.

5. By signing this form, I attest that the information provided on this form is accurate and true.

Print Name_____________________________________

Signature_______________________________________

Date__________________________

FOR OFFICE USE ONLY

DATE RECEIVED ___________________	COMPLETE ___________________	INCOMPLETE _________________
RAHF STAFF _______________	RAHF Signature _______________	COMMENTS _________________

CERTIFIED, REGISTERED MAIL To

ISAI, Inc.

7942 W. Bell Road C5. # 298

Glendale AZ 85308

or to

DHL OR CERTIFIED REGISTERED MAIL to

ISAI, Inc. 6013 W. Monte Cristo, Glendale, AZ 85306.

Payment or submission information -

All documents and payments must be sent to ISAI, Inc. 6013 W. Monte Cristo, Glendale, AZ 85306. Send certified check or money order, payable to ISAI to:

ISAI, Inc. 6013 W. Monte Cristo, Glendale, AZ 85306. All required registration forms must be copied, and three copies for each team sent with payment by registered, certified mail to above address. The other option is to send copies of the application by certified, registered mail, or DHL with payment to above address. Because of internet insecurity in many African countries, no applications can be sent by email. ALL APPLICATIONS MUST BE ACCOMPANIED BY PAYMENT. SENDING APPLICATIONS AND PAYMENT BY DHL IS PROBABLY YOUR BEST OPTION.

Here's How To Submit Your Application.

ISAI Contact Information

Dr. Carol Cross, Director

The International Sports Adventure Institute, Inc.

Supporting Soccer Based Development Through Honduras Soccer Camps, Intibuca International Youth Tournament, AfroCarib International Youth Tournament, the Copa Weshemisphere Friendlies and the LigaAmericás Soccer Mastery Academy. AfroHeritage Soccer Players - Join the RED de AfroHeritage Footballers. AfroHeritage Soccer Players - Play in the African/Caribbean Youth Soccer Tournament in October 2004.

Soccer is our Passion, Our Love, and Our Focus at ISAI. We work with Youth At Risk in Arizona and Honduras through our support for Soccer For Life, Inc, a non profit organization. Subscribe to free Soccer Mastery newsletter based on the LigaAmericás Soccer Mastery Academy opening in 2004 in La Esperanza Honduras in La Esperanza, Honduras.- send email to exportfacs@aol.com. For a FREE subscription to Weshem Torneo - an online magazine designed to help groups put on soccer tournaments send email to honducopa@yahoo.com. .

Home Page: www.satglobal.com/soccer_entry.htm

Email to honducopa@yahoo.com

Phone : 602-564-9241 Fax: 602-564-9243

International Sports Adventure Institute, Inc., DBA ISAI, has no liability for contents or goods on the Internet except as set forth in the Terms and Conditions Of Services.

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