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2. Name*
3. Email Address*
5. Address*
7. City*
8. State
9. Zip Code
11. Phone Number
15. Employer
16. Address
18. Date Started
    Date Started
19. Job Title
20. If no longer employed, please specify Date Left and Reason for Leaving
22. Work Performed/Responsibilities
24. Supervisor
25. Supervisor's Phone
27. May we contact for a reference?

    1. Yes
    2. No
31. Desired Program(s):*

    1. Soccer
    2. Track and Cross Country
    3. Lacrosse
    4. Boys Basketball
    5. Girls Basketball
    6. Little League
    7. Softball
    8. Babe Ruth Baseball
    9. Football and Rockets Cheerleading
    10. Competition Cheerleading

    Check all programs you would like to receive a copy of this application

32. Desired Position*

    1. Coach
    2. Assistant Coach
    3. Team Manager
    4. Official (Umpire, Referee, etc.)
36. LIst all Coaching and other relevant experience:*
    Please include approximate dates, position held, sport and organization affiliation
37. List all Current and Valid Certifications applicable to Recreation and Athletic Programs:
    Please include certificate name, certifying agency and expiration date
39. Rutgers Clinic Date Taken:
    Rutgers Clinic Date Taken:
40. Rutgers Clinic Location:
44. Have you ever been convicted of a crime other than a minor traffic violation?*
    -- Select One --NoYes
45. If yes, state what the conviction was for, the town and the state where the conviction was made, and the date.
47. Have you ever been convicted of driving under the influence?*
    -- Select One --NoYes
48. If yes, state the town and state where the conviction was made and the date of conviction.
50. Are you currently required to register with a law enforcement agency under Megan's Law?*
    -- Select One --NoYes
54. Additional personal references we may contact:
56. Name
57. Address
59. Phone Number
60. Years Known
    Years Known Start Date

    —

    Years Known End Date
62. Name
63. Address
65. Phone Number
66. Years Known
    Years Known Start Date

    —

    Years Known End Date
70. By entering my full name in the space below, I certify that the information provided by me is true and accurate to the best of my knowledge. I understand that if any such information is willfully false, I am subject to punishment. I further understand that falsification of this application and any content herein may result in dismissal as a volunteer from Rockaway Township programs. I authorize Rockaway Township to investigate all statements contained in this application. *
Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit

* indicates a required field