PERSONAL INFORMATION
Full Name:
Social Security Number:
Address:
City:
State:		- Select One -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming
Zip Code:
Number of years at present address:
Home Phone:		( ) -
Work Phone:		( ) -
Previous Address:
City:
State:		- Select One -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming
Zip Code:
Number of years at previous address:
VOLUNTEER OPPORTUNITY DESIRED
Area of Interest:		- Select One -AquaticsChild CareHealth & FitnessYouthOther
Location:		- Select One -BeverlyCape AnnHaverhillIpswichMarblehead/SwampscottSalem
Date Available:
Are you presently employed?:		Yes No
If yes, may we contact your present employer?:		Yes No
Have you ever volunteered for the YMCA of the North Shore before?:		Yes No
If yes, please specify date, branch and department below.
Branch Information:
Do you have friends or relatives currently volunteering or working for the YMCA?:		Yes No
If yes, please specify date, branch and department below.
Branch Information:
EDUCATION AND TRAINING
Elementary School:
Years Attended (year/year):
Graduate?:		Yes No
High School:
Years Attended (year/year):
Graduate?:		Yes No
College/University:
Years Attended:
Graduate?:		Yes No
Degree:
Other:
Years Attended (year/year):
Graduate?:		Yes No
Degree:
Highest Degree Earned:
High School  Associate  Bachelor  Master
Please list all current certifications, job related skills, and/or related training experiences below.
Experience, Skills, Experience:
Please list all promotional memberships, certificates or licenses held below. (Exclude those indicating race, color, religion, sex, sexual orientation, national origin, age, physical or mental disability or labor organization affiliations.)
Memberships, Certificates, Licenses:
REFERENCE DATA
Below, please provide information for three individuals who are not relatives that we may contact.
Individual One:
Individual Two:
Individual Three:
EMPLOYMENT DATA
Please list in order of most recent employment first.
Company Name 1::
Address:
City:
Zip Code:
Phone Number:		( ) -
Dates of Employment (year/year):
Job Title - Start:
Job Title - Final:
Description of Job Duties:
Supervisor Name & Title:
May we contact?:		Yes No
Company Name 2::
Address:
City:
State:		- Select One -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming
Zip Code:
Phone Number:		( ) -
Dates of Employment (year/year):
Job Title - Start:
Job Title - Final:
Description of Job Duties:
Supervisor Name & Title:
May we contact?:		Yes No
PERSONAL INFORMATION
Are you less than 18 years of age?:		Yes No
Have you ever been convicted of a felony?:		Yes No
(A conviction will not necessarily disqualify you.)
Have you ever been convicted for child abuse or sex-related crimes?:		Yes No
If yes, please explain below:
Please Explain:
Please answer the following question in the space provided below: Within the last 5 years, have you been convicted of, or ended a period of incarceration resulting from, a conviction for a misdemeanor other than first convictions for drunkenness, simple assault, speeding, a minor traffic violation, an affray, or disturbing the peace? If yes, describe in full.
Answer from above:
Please note: If you have a scaled record on file with the Commissioner of Probation you may answer "no record" with respect to an inquiry herein relative to prior convictions. In addition, any applicant for employment may answer "no record" with respect to an iquiry to prior adjudications in all cases of delinquency or as a child in needs of services which did not result in a compliant transferred to Superior Court and resulting in conviction. The Criminal History Systems Board and Security Privacy Council certified the YMCA of the North Shore for access to conviction data concerning present and prospective volunteers who will have the opportunity for contact with children.

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