Employment Application - South Side Youth SenterSouth Side Youth Senter

Personal Information

Prospective employees will receive consideration without discrimination because of race, creed, color, age, sex, national origin, or handicap.

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Residency*

Please List ALL cities and states that you have lived in within the past 5 years.

Phone*

Email*

Are you an US Citizen?*

Social Security Number*

DL Number

State Issuing DL

Date of Birth*

Employment Desired

Position Desired*

Please check all that apply.

After School Care
Sports Program Assistant
Van Driver (must be at least 21 years old)
Sports Director (Must be at least 21 years old)

Date Available to Start*

Salary Desired

Are you currently employed?*

Yes
No

Have you ever applied to Southside Youth Senter before?*

Yes
No

If yes, when?

Have you ever worked at Southside Youth Senter before?*

Yes
No

If yes, when?

Employment History

Previous Employers

Please list previous employers for the last 5 years, if applicable.

Company Name	Phone	Supervisor	Ending Pay/ Hr	Date Hired	Date Ended	Reason for Leaving

Education

Please list your educational background*

Institution	Degree	Major	Graduation Date

Certifications:

Type of Certification	Issue Date	Expiration Date

Other Information

Other Involvement

I am involved in the following activites at school and in the community:

Additional Information

Please list any special training or skills you would like to have considered.

Shifts Available to Work (After-School Program)

Please check all that apply. All day shifts may be required during school breaks.

Select All
Monday 2:45-5:30
Tuesday 2:45-5:30
Wednesday 2:45-5:30
Thursday 2:45-5:30
Friday 2:45-5:30

Shifts Available to Work (Sports Program)

Please check all that apply. All day shifts may be required during tournaments.

Select All
Monday 4:15pm-9:15pm
Tuesday 4:15pm-9:15pm
Wednesday 4:15pm-9:15pm
Thursday 4:15pm-9:15pm
Friday 4:15pm-9:15pm
Saturday 7:30am- 12:15pm

Signature*

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, false statements on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they have, personal or otherwise, and release Southside Youth Senter (SYS) from all liability for any damage that may result from utilization of such information.
I also understand and agree that no representativeof SYS has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the forgoing, unless it is in writing and signed by an authorized SYS representative.
This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."

I agree

Date*