YMCA Employment/Volunteer Application

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The Kosciusko Community YMCA is an Equal Opportunity Employer. Applicants for all job openings are welcome and will be considered without regard to race, color, religion, national origin, sex, age, sexual orientation, physical or mental disability, or any other basis protected by state, federal or local law. It is the intent of the association to comply with all applicable federal, state and local legislation concerning equal opportunity in employment. Proof of citizenship or authorization for employment in the USA is required before final selection. The Kosciusko Community YMCA is committed to protecting the health and safety of our employees.

Our Mission: To put Christian principles into practice through programs that build healthy spirit, mind and body for all.

Personal Information
Name: (First & Last)
Address: (Street Number & Name, City, State, Zip Code)
Number of years at present address?
Home Phone:
Email Address:
Cell Phone:
Previous Address: (Street Number & Name, City, State, Zip Code)
Number of years at previous address?
Can you, after employment, submit verification of your legal right to work in the United States?
Are you over 18?
If hired, do you have a reliable means of transportation to get to work?
Have you ever been convicted of a felony, or for child abuse or sex-related crimes? You need not disclose information regarding convictions that have been annulled, expunged, sealed, pardoned, erased, impounded or restricted (Indiana Second Chance Law).
If yes, please explain: (A conviction will not necessarily disqualify you.)
Do you have any pending charges against you?
If yes, please explain:
Employment Desired
Type of Position desired:
Position Desired:
Date Available
Salary Desired:
Are you presently employed?
If yes, may we contact your present employer?
Have you ever applied at the YMCA before?
If yes, when?
Have you ever been employed by the YMCA before?
If yes, when?
How were you referred to the YMCA:
Employee Name:
Please Specify:
Education & Training
Entry 1
High School: (Name & Location)
Graduate?
Degree:
Major:
Entry 2
College/University: (Name & Location)
Graduate?
Degree:
Major:
Entry 3
College/University: (Name & Location)
Graduate?
Degree:
Major:
Highest Degree Earned:
Additional Education, Vocational and/or Professional Information such as special areas of research or study, seminars, etc. Please attach any written resume or other summary of information that is relevant to the position for which you are applying. If familiarity with a foreign language is listed on the job description, please describe your foreign language skills below.
All new hires must be CPR certified as a condition of employment. All staff involved in any childcare program, management staff and fitness monitors are also required to have First Aid certification prior to employment. If I'm not certified upon hire, I understand that the YMCA will assist me in getting the certification, but I will not be compensated for my time to take the class. My initials below show that I understand this.
U.S. Military Service Data
Branch:
List Special Training or Skills:
Employment Data

Please list in order of the most recent employment first.

Employment 1
Company Name:
Phone:
Employment From:
Employment To:
Address: (Street Number and Name, City, State, Zip Code)
Job Title:
Base Pay Start:
Base Pay Final:
Supervisor: (Name & Title)
Description of Job Duties:
Reason for Leaving:
Additional Comments:
Employment 2
Company Name:
Phone:
Employment From:
Employment To:
Address: (Street Number and Name, City, State, Zip Code)
Job Title:
Base Pay Start:
Base Pay Final:
Supervisor: (Name & Title)
Description of Job Duties:
Reason for Leaving:
Additional Comments:
Employment 3
Company Name:
Phone:
Employment From:
Employment To:
Address: (Street Number and Name, City, State, Zip Code)
Job Title:
Base Pay Start:
Base Pay Final:
Supervisor: (Name & Title)
Description of Job Duties:
Reason for Leaving:
Additional Comments:
Reference Data

Professional/work references that we may contact, please do not list friends or family.

Reference 1
Name:
Email:
Phone Number:
Relationship:
Reference 2
Name:
Email:
Phone Number:
Relationship:
Reference 3
Name:
Email:
Phone Number:
Relationship:
Pre-Employment Certification

I understand that this application is only valid for the position applied for at present and that the Kosciusko Community YMCA is not obligated to retain or consider this application for future openings. (initials)

I authorize investigation of all statements contained in this application. I understand that falsification, misrepresentation or omission of facts called for will result in immediate termination from employment or removal of my application from consideration. I authorize the Kosciusko Community YMCA to secure information about my experience with my references, former employers, education institutions and agencies, and for those parties to provide information concerning my experience releasing all parties from any liability arising there from. (initials)

If employed by the Kosciusko Community YMCA I will abide by association policies, procedures, and rules. I understand that I will be required to possess a current and valid driver's license if my position requires me to drive in the course of my work. (initials)

I agree to submit to legally permissible drug and/or alcohol testing and a background check upon request by the Kosciusko Community YMCA. I recognize that the results of these tests may be used to determine my employment or continued employment. I understand and expressly agree that if employed by the Kosciusko Community YMCA storage areas provided for me (locker, desk, computer, etc.) are open to investigation by the Kosciusko Community YMCA without prior notice to me. (initials)

If I am employed by the Kosciusko Community YMCA I understand my employment can be terminated, with or without cause and with or without notice, at any time at the option of the Kosciusko Community YMCA or myself. I understand that, other than the Chief Executive Officer of the Kosciusko Community YMCA no manager, supervisor or representative of the YMCA has authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing. Only the Chief Executive Officer of the Kosciusko Community YMCA has the authority to make any agreement contrary to the foregoing and then only in writing. I further expressly agree that, with respect to the at-will employment relationship, this constitutes the full, complete and final expression of the parties' intent concerning the nature of any employment relationship between myself and the Kosciusko Community YMCA. (initials)

My signature below 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.

My signature below also certifies that I agree to be bound by the terms and conditions stated in this application. This application contains all the understandings and agreements between me and the Kosciusko Community YMCA concerning the nature of my employment, if any, by the YMCA and supersedes all prior and/or contemporaneous practices, oral or written agreements, understandings, statements, representations and promises, express or implied, between me and the Kosciusko Community YMCA. I understand and agree that, except as noted above, no person who is either an agent or employee of the YMCA may modify, delete, vary or contradict, whether orally or in writing, the terms and conditions set forth herein.

Applicant Signature:
Date of Application:
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