The YMCA of the North Shore is committed to the values of caring, honesty, respect and responsibility. Our YMCA provides all children, adults, and families, regardless of income, with opportunities to develop a healthy spirit, mind and body.
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:
Can you, if offered employment, submit verification of your legal right to work in the United States?:		Yes No
EMPLOYMENT DESIRED
Position applying for:
Location:
Date Available:
Are you presently employed?:		Yes No
If yes, may we contact your present employer?:		Yes No
Have you ever worked 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 working for the YMCA?:		Yes No
If yes, please list name, branch and department below.
Specify Information:
Type of work desired:
Full Time  Part Time  Seasonal  Temporary  Educational Co-op
Please check:
Days  Nights  Evenings  Weekday  Weekends
How were you referred to the Association:
Advertisement  Employee  Referral  Walk-In  Agency  Other
If you selected Employee Referral, please enter the name of employee, position, and location below.
Employee 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 (year/year):
Graduate?:		Yes No
Other:
Highest Degree Earned:
High School  Associate  Bachelor  Master
Please list all current certifications, job related skills, and/or related training experiences in the space below. If familiarity with a foreign language is listed on the job description, please also describe your foreign language skills below.
Certificates/Skills/Experience:
Below, please list professional memberships, certificates or licenses held. (Exclude those indicating race, color, religion, sex, sexual orientation, national origin, age, physical or mental disability or labor organization affiliations.)
REFERENCE DATA
Below, please provide information for three individuals who are not relatives that we may contact. Please include the following: Relationship, Address, Phone and Years Known.
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:
Base Rate of Pay - Start:
Base Rate of Pay - Final:
Description of Job Duties:
Supervisor Name & Title:
May we contact?:		Yes No
Company Name 2::
Address:
City:
Zip Code:
Phone Number:		( ) -
Dates of Employment (year/year):
Job Title - Start:
Job Title - Final:
Base Rate of Pay - Start:
Base Rate of Pay - Final:
Description of Job Duties:
Supervisor Name & Title:
May we contact?:		Yes No
Company Name 3::
Address:
City:
Zip Code:
Phone Number:		( ) -
Dates of Employment (year/year):
Job Title - Start:
Job Title - Final:
Base Rate of Pay - Start:
Base Rate of Pay - 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
If yes, can you provide a Work Permit/Education Certificate?:		Yes No
Have you ever been convicted of a felony?:		Yes No
If yes, please explain below (a conviction will not necessarily disqualify you.)
Please Explain:
Have you ever been convicted for child abuse or sex-related crimes?:		Yes No
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? Please answer below.
If yes, describe in full below:		Yes No
Please Explain:
Please note: If you have a sealed record on file with the Commissioner of Probation you may answer inno recordlo with respect to an inquiry herein relative to prior convictions. In addition, any applicant for employment may answer inno recordle with respect to an inquiry relative to prior adjudications in all cases of delinquency or as a child in needs of services which did not result in a complaint 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 employees who will have the opportunity for contact with children.
PRE-EMPLOYMENT CERTIFICATION
Notice to Employment Applicants: I understand that this application, the Association handbooks, policies, practices, procedures, and all other communications by the Association do not create contractual rights or entitlements, and may be modified or eliminated by the Association at any time, in its sole discretion. If I am hired, I understand that my employment is at will and may be terminated by me or the Association at any time, with or without cause or notice. Any agreement contrary to the foregoing must be in writing and must be signed by the CEO of the Association and me. I certify that the information contained on this application form is accurate and complete in all respects. I understand that the information and references regarding me may be investigated by the Association or its agents, and that giving inaccurate or incomplete information may result in my being rejected for employment, or, if discovered after my employment commences, may result is disciplinary action up to and including termination of employment. I authorize the YMCA Association to verify all information I have provided on this application form. I release anyone from any and all liability to me, which could result from their disclosure of information in response to the Association™s inquiries. A photocopy of this authorization and release may be considered as valid as an original. It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment. Any employer who violates this law shall be subjected to criminal penalties and civil liability. I understand and expressly agree that if employed by the Association, storage areas provided for me (locker, desk, e-mail, etc.) are open to investigation by the Association without prior notice to me. By clicking the box below, it certifies that I have read and understand the foregoing and to the best of my knowledge and belief, the information on this form is true and correct.
Certifies that information is correct: