About - YMCA of South Hampton Roads

Employment Opportunities

Instructions (please print): please answer each question completely and accurately. Be careful to include city, state and zip code for all addresses, as well as area codes for telephone numbers. Your application will remain active for three months. You will be contacted only if YMCA of South Hampton Roads has a vacancy for which you are being considered.

BASIC INFO

Today’s date

Position(s) applied for

Branch

Last Name

First Name

^MI

Nickname

Street Address, Route No. etc.

Apt. Number

City

State

Zip Code

Home Phone No.

Alternative Telephone No.

Work No?

Are you legally employable in the US?

May we contact your present employer?

Have you ever been employed by the YMCA of South Hampton Roads?

Have you ever been employed by the YMCA in the U.S. or in any other country? " Have you ever been employed by the YMCA in the U.S. or in any other country?

If yes to either of the two above, provide location, department and dates:

How were you referred to the YMCA?
(please be specific)

If other:

Type of employment desired:

If part time:

Hourly rate or annual salary desired (mandatory):

Salary type:

Have you used any name other than the name you are now using while attending school or in a previous employment?
If yes, list name(s) and dates used:

If you have relatives employed by the YMCA of South Hampton Roads, list names, relationships, position and branch:

Have you ever been convicted of a felony, or are you the subject of pending felony charges? Conviction will not necessarily disqualify you from employment, failure to disclose this information may disqualify you from further consideration

If yes, please explain and list dates:

EDUCATION

Type of School	Name of School	Major field or course of study	Dates attended		Hours completed	Degree/Cert. Earned
			From mo/yr	To mo/yr
High School or GED
						Grad.yes/no
University or College
						Grad. yes/no
University or College
						Grad. yes/no
Vocational or Other
						Grad. yes/no
Awards scholarships, honors received:			Other activities, class offices, etc.:
List any professional licenses or designations and dates received:

SKILLS / CERTIFICATION
Check any of the following skills or certification you possess

Computer Skills	Certifications
MS Word	Lifeguard	First Aid	CPR
MS Word	Expiration	Expiration	Expiration
Excel	Aerobics	Teaching	CDL
Excel	Expiration	Expiration	Expiration
Publisher	Early Childhood Education
Access	Expiration
Powerpoint	Other:
Internet

Describe any training relevant to the position for which you are applying:

REFERENCES
Please list at least three references that we can contact (work-related preferred)

1. Name	Relation:	Phone
Address	City/State	Zip
2. Name	Relation:	Phone
Address	City/State	Zip
3. Name	Relation:	Phone
Address	City/State	Zip
4. Name	Relation:	Phone
Address	City/State	Zip

PRIOR WORK HISTORY
(List in order, last or present employer first, including self-employed)
(Resume may be attached but not substituted for completing information below)

Dates		Name of Organization ^{Street Address, City, State, Zip}	Hourly Rate or Annual Salary		Supervisor’s name and title	Reason for leaving or wanting to leave
^From	^To		^Start	^{Final/Present}

Your position title:				Employment Status May we contact your present/previous supervisor:
Summary of duties:

Dates		Name of Organization ^{Street Address, City, State, Zip}	Hourly Rate or Annual Salary		Supervisor’s name and title	Reason for leaving or wanting to leave
^From	^To		^Start	^{Final/Present}

Your position title:				Employment Status May we contact your present/previous supervisor:
Summary of duties:

Dates		Name of Organization ^{Street Address, City, State, Zip}	Hourly Rate or Annual Salary		Supervisor’s name and title	Reason for leaving or wanting to leave
^From	^To		^Start	^{Final/Present}

Your position title:				Employment Status May we contact your present/previous supervisor:
Summary of duties:

List any reason for any gaps between dates of employment:

Membership in Professional and Civic Organizations (exclude those which may disclose race, color, religion, gender, age or national origin):

SUPPLEMENTAL INFORMATION

The YMCA of South Hampton Roads is an organization in which management and employees are bound together by common goals. To this end, we are interested in career goals of all of our present or potential employees. In the space provided below, please indicate what you believe your career goals to be. Thank you for your interest in the YMCA of South Hampton Roads.

List any additional information you believe significant to your application:

APPLICANT’S CERTIFICATION AND AGREEMENT

The undersigned hereby expressly authorizes and directs the confidential release of my scholastic/employment and/or criminal history record to the YMCA of South Hampton Roads for the sole purpose of employment evaluation. In addition, I understand that all YMCA employees are
subject to the YMCA’s policy on drugs and alcohol and are subject to its terms. Part of the YMCA’s application process may include a urine/ drug test. I hereby give my consent to the YMCA and any laboratory or any healthcare provider that the YMCA may designate to collect ant test urine, blood or breath samples to indicate the presence of illegal drugs or alcohol. In consideration of employment, I agree to conform to the rules and policies of the YMCA of South Hampton Roads and I understand and acknowledge that my employment may be terminated at any time, with or without cause, and with or without notice at the option of either the YMCA or myself. Each and every statement and fact set
out in this application for employment is true and correct to the best of my knowledge. I acknowledge that any discrepancy may be grounds for termination of my employment at any time hereafter. I hereby authorize the YMCA of South Hampton Roads to investigate the statements and answers which I have made on this application. I understand that no Branch Executive or any other employee of the YMCA of South
Hampton Roads, other than the President/CEO, has any authority to enter into any agreement with me for my employment for any specified period of time ,or to make any agreement contrary to the foregoing.

Please sign that you have read and understand the Applicant’s Certification and Agreement. Your application will be processed as quickly as possible.

Date:________________________________
Signature (submission of this application substitutes an authorized hand signature):______________________