Employment Application Employment Application Personal InformationProspective 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?*YesNoSocial Security Number*DL NumberState Issuing DL Date of Birth* MM slash DD slash YYYY Employment DesiredPosition 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* MM slash DD slash YYYY Salary DesiredAre 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 HistoryPrevious EmployersPlease list previous employers for the last 5 years, if applicable.Company NamePhoneSupervisorEnding Pay/ HrDate HiredDate EndedReason for Leaving EducationPlease list your educational background*InstitutionDegreeMajorGraduation Date Certifications:Type of CertificationIssue DateExpiration Date Other InformationOther InvolvementI am involved in the following activites at school and in the community:Additional InformationPlease 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 agreeDate* MM slash DD slash YYYY