FIRST NAME
LAST NAME
MIDDLE NAME
LOCAL ADDRESS
CITY
STATE
ZIP
PERMANENT OR PARENTS ADDRESS
PERMANENT ADDRESS
CELL PHONE #
HOME PHONE #
POSITION APPLYING FOR (PLEASE CHECK): LIFEGUARD MEMBER SERVICES CHILD WATCH
JANITORIAL YOUTH & ATHLETIC PROGRAMS DAY CAMP OTHER
EMAIL ADDRESS
HIGH SCHOOL
DATE OF GRADUATION
COLLEGE
YRS COMPLETED FR. SOPH. JR. SR.
DEGREE EARNED
MAJOR
MINOR(S):
OTHER TRAINING/CERTIFICATION: (EXAMPLE: CPR, LIFESAVING, AFAA)
COURSE
DATE
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PREVIOUS EMPLOYERS: (List the last three employers starting with the most recent)
COMPANY
POSITION
EMPLOYMENT START DATE
EMPLOYMENT END DATE
SUPERVISOR
PHONE #
REASON FOR LEAVING
HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEANOR? PLEASE CIRCLE: YES or NO
IF SO, DATE
CHARGE
NAME
ADDRESS
IN THIS SECTION PLEASE WRITE A BRIEF STATEMENT AS TO WHY YOU WANT TO WORK FOR THE YMCA
“I certify that the information contained in this application is true and accurate to the best of my knowledge. I understand that falsification of this application in any detail is grounds for disqualification from further consideration and/or for dismissal from employment. I hereby authorize the YMCA to contact my previous employers and my personal references and I understand the YMCA may choose to do background investigation which may involve contacting some or all of the following sources:
Criminal Court Clerk, Department of Human Services, and any relevant state bureau. I hereby authorize all of these sources to release information about me, and I understand that the YMCA may contact sources not listed herein.
I agree to conform to the rules and policies of the YMCA and understand that my employment and compensation can be terminated, with or without cause, at any time, at the option of either the YMCA or myself. I understand that no representative of the YMCA has any authority to enter into any agreement for employment for any specified period of time, unless the agreement is in writing and signed by the Executive Director.”
SIGNATURE
Equal Employment Opportunity: It is a policy of the YMCA to implement the Equal Opportunity Act for all employees and applicants for employment without regard to race, creed, religion, mental or physical disability, national origin, color, ancestry, sex and age.
Professional/Employer References to Be Completed by YMCA. References must be verified PRIOR to hiring prospective employee. Please include comments.
Name of Applicant:
Date of Contact (for YMCA staff use):
Name
Phone 1
Phone 2
Years Known
Comments
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