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110 North Galena Dixon, Illinois 61021
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Position Applying For:
Date Format: MM slash DD slash YYYY
Address Line 2
State / Province / Region
ZIP / Postal Code
Antigua and Barbuda
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Congo, Democratic Republic of the
Congo, Republic of the
French Southern Territories
Heard and McDonald Islands
Isle of Man
Lao People's Democratic Republic
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Svalbard and Jan Mayen Islands
Trinidad and Tobago
Turks and Caicos Islands
United Arab Emirates
US Minor Outlying Islands
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Are you 18 years of age or older? (If not, you may be required to provide work authorization.)
If hired, can you provide verification of your legal right to work in the United States?
Can you perform the essential functions of the job for which you are applying, with or without reasonable accommodation?
Notice to All Applicants: The YMCA enforces its policies and practices to prevent child abuse.
Allegations or suspicions of child abuse are taken very seriously at the YMCA and will be reported to the proper authorities for investigation. We have abuse reporting procedures, there are unscheduled visits from supervisors, we have an open door for parents, and we have a code of conduct for staff. We minimize opportunities for abuse to occur and we talk with children about personal safety and touching limits. We also screen carefully to prevent abusers from being hired and we provide child abuse prevention training to staff. A criminal background check may be required of any applicant who is selected for an interview or to whom a conditional offer of employment is made.
List available days/hours:
Preferred Job Status:
Have you previously been employed by this YMCA or any other YMCA?
No If yes, when? At which locations?
Have you previously volunteered at this YMCA or any other YMCA?
If yes, when? Which programs?
Do you have any relatives or household members currently working for this YMCA?
No If yes, name(s) and relationship:
How did you hear about this opening?
YMCA staff referral
Name of referral source:
Education & Training
High School or GED Information:
Graduate School Information:
Technical or Vocational School Information:
Describe any non-employment experience such as school or volunteer activities that might strengthen your application:
Safety & Job Specific Certifications that are Current
List all previous employment during the past seven years starting with the Employment History most recent. Use additional sheets if needed.
Employer 1 Telephone
Employer 1 Dates employed:
Employer 1 Address:
Employer 1 Job Title:
Employer 1 Immediate Supervisor and Title:
Employer 1, Summarize the nature of the work performed and job responsibilities.
Employer 1, Reason for Leaving
Employer 1, May we contact this employer?
Employer 2 Telephone
Employer 2 Dates employed:
Employer 2 Immediate Supervisor and Title:
Employer 2 Address:
Employer 2, Summarize the nature of the work performed and job responsibilities.
Employer 2, Reason for Leaving
Employer 2, May we contact this employer?
Employer 3 Telephone
Employer 3 Dates employed:
Employer 3 Immediate Supervisor and Title:
Employer 3 Address:
Employer 3, Summarize the nature of the work performed and job responsibilities.
Employer 3, Reason for Leaving
Employer 3, May we contact this employer?
Please explain any gaps in your employment history.
What other business experience, personal experience or training have you had that may have prepared you for this position?
Personal Reference 1
Reference 1 Name:
Reference 1 Occupation:
Reference 1 Years Known:
Reference 1 Years Address, City, State and Zip.
Reference 1 Email:
Reference 1 Phone:
Reference 1 Alternate Phone:
Personal Reference 2
Reference 2 Name:
Reference 2 Occupation:
Reference 2 Years Known:
Reference 2 Years Address, City, State and Zip.
Reference 2 Email:
Reference 2 Phone:
Reference 2 Alternate Phone:
Personal Reference 3
Reference 3 Name:
Reference 3 Occupation:
Reference 3 Years Known:
Reference 3 Years Address, City, State and Zip.
Reference 3 Email:
Reference 3 Phone:
Reference 3 Alternate Phone:
Application Acknowledgement and Authorization
I agree to the following:
Please read all statements and sign below:
I authorize both the YMCA and persons listed (references, schools, current (unless noted) and former employers and any others with whom you desire to check) to communicate with regard to any relevant information that may be required to reach an employment decision. I agree to hold such persons harmless with respect to any information they may supply. I understand and agree that any offer of employment is contingent upon successful completion of all background check processes, including a criminal history background check.
I certify that all information provided by me in this application is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation, or omission of any facts in this application or any other document submitted in connection with YMCA employment will result in denial of employment or termination of employment regardless of the timing or circumstances of discovery.
If I am employed by the 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 YMCA or myself. I understand that, other than the CEO of the 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 CEO of the 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 YMCA.
I understand that all offers of employment are conditional upon my ability to provide appropriate documents regarding my identity and legal right to work in the United States. I understand that this application is only valid for the position applied for at present and that the YMCA is not obligated to retain or consider this application for future openings. If hired, I agree to abide by YMCA policies and rules at all times. I acknowledge that I have read the above statements and understand them.