Employment Application -

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/State ID Number

State Issuing DL or State ID*

Date of Birth*

Employment Desired

Position Desired*

Please check all that apply.

Child Care Program Assistant
Sports Program Assistant
Van Driver (must be at least 21 years old)
Volunteer
America Reads Tutor (MSUTexas Work Study Only)

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?

Are you an MSUTexas Student?*

Yes
No

IF you are an MSU Texas Student, what is your M#

May we contact MSU Texas Financial Aid Office on your behalf to check Work Study Eligibility?

Yes
No

Are you Work Study Eligable?

Yes
No
I'm Not Sure

Availability

Please select the days you and times you are avaialable to work

Monday

Available

Availability Start

:

Availability Ends

:

Tuesday

Available

Availability Start

:

Availability Ends

:

Wednesday

Available

Availability Start

:

Availability Ends

:

Thursday

Available

Availability Start

:

Availability Ends

:

Friday

Available

Availability Start

:

Availability Ends

:

Saturday

Available

Availability Start

:

Availability Ends

:

Employment History

Previous Employers*

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

Company Name	Phone	Supervisor	Ending Pay/ Hr	Date Hired	Date Ended	Reason for Leaving	May we contact?

Education

Please list all education including High School, Technical/ Vocational school, Junior/ Community College, and/or University work.

Please list your educational background*

Institution	Degree	Major	Graduation Date

Certifications:

Type of Certification	Issue Date	Expiration Date

Please list any and all specialized certifications you have received (I.e. CPR/First Aid, Child Development Associates Credential, etc.)

References

Reference Name:	Reference Type: (Professional, Educational, or Personal?)	Years known	Job Title	Employer	Phone Number:	Email:

Please Provide 3 Professional or Educational references.

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.

Consent to Background Check and Fingerprinting*

Southside Youth Senter is regulated by the Texas Department of Health & Human Services Child Care Regulation Division. According to Texas Administrative Code, Chapter 745, Subchapter F, Rule 745.605: All employees, prospective employees, and volunteers who are frequent visitors (2+ times/month)must undergo background checks and fingerprinting as instructed by Texas Child Care Regulation Centralized Background Check Unit. Failure to meet all requirements as instructed by TX CCR CBCU will result in ineligibility of hire or volunteering.

I agree to undergo a Background Check and Fingerprinting as required by Texas Child Care Regulation Centralized Background Check Unit.

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*