SOCCER LEAGUE FIELD USE PERMIT APPLICATION
Fall 2016-Spring 2017
This form must be received prior to Sunday, June 5, 2016.
This form cannot be saved. Please gather all necessary documents and complete this form from start to finish.
Name of Organization:
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Democratic Republic of the Congo
Republic of the Congo
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
United States Minor Outlying Islands
Virgin Islands, British
Virgin Islands, U.S.
Level of Play Requested:
Separate permit applications are required for each level of play. Refer to
Community Soccer Field Use Policy
for eligibility requirements
General Recreation (DSL Only)
Please estimate the number of
at this level of play for each of the following age groups (Fall season only):
U5 (DSL Only)
U6 (DSL Only)
U7 (DSL Only)
U15 & up (Spring Only)
Organizations must maintain their primary office address within the corporate limits of the City of Dublin. Please attach proof of obtaining a current City income tax filing number or exemption.
Please attach documentation of the organization's tax-exempt status with the Internal Revenue Service (i.e., IRS determination letter).
Organizations must demonstrate compliance with tax return filing requirements. Please attach the most recent federal tax filing submitted to the Internal Revenue Service (Form 990).
Organizations must secure general liability insurance for the minimum amount of $1,000,000, naming the City of Dublin as additional insured. Organizations must notify the City of Dublin immediately if the insurance has been canceled or changed. Please attach a copy of this insurance certificate.
If applicable, please submit the organization's written policy regarding the amount of expected game playing time exposure for participants.
Please attach a copy of the organization’s Code of Regulations or Bylaws and roster of its Board of Directors.
Please attach the organization’s written code of conduct for athletes, spectators and coaches that stresses the importance of good character and specifies ethical obligations and sportsmanship expectations.
Please attach the organization’s policy delineating established disciplinary procedures for addressing behavioral problems of athletes, coaches, officials and spectators.
Please attach the organization’s emergency communication plan used by the organization to ensure that all member coaches and teams are aware of any severe weather policies or emergency advisory systems. (It is the responsibility of the organization or league representative, scheduled referee(s), or permit holder to determine whether or not conditions will endanger the safety of the participants and whether or not the activity will have serious adverse effect on field conditions).
Please attach the organization’s previous year’s game schedules, indicating the number of games played on City fields.
Please attach a copy of all participant registration fees for the previous season and upcoming season.
Please read the following statements and acknowledge below:
Criminal background checks are required for all organization representatives, including all coaches, volunteers, staff, Board of Director members and committee chairs. The process used to conduct such tests must be approved by the City in advance.
Results and documentation of all background checks conducted must be submitted annually prior to the start of each fall season
, and prior to the commencement of any new individual representing the organization throughout the year. The City reserves the right to conduct an additional independent background check for any individual and may determine the eligibility of participation or representation based on the results of such checks.
It is the responsibility of the organization to inform the City of Dublin of any coaching additions or changes during the season and to provide appropriate documentation.
A list of all completed background checks must be submitted prior to the start of each season. If you would like to submit your list now, please attach it here. Otherwise, please note that you will need to send it electronically to the Sports Program Supervisor per the deadline above.
For league play applications, a non-refundable deposit in the amount of 50% of
the projected field use fee will be collected once the application has been
approved. Final roster submission and payment will be required at the end of each Fall & Spring season according to the fee schedule in
of the policy.
Failure to comply with any standards stated in the policy may result in, but not limited to, an organization's forfeiture of the permit and future eligibility for priorities 1-4.
I have read and understand the requirements as stated in the City of Dublin Soccer Field Use Policy.
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