Employment Application : How To Help : Boys & Girls Club of Cabarrus County

SECTION I

First Name (Required)

Middle Name (Required)

Last Name (Required)

Date of Birth (Required)

Phone 1 (Required)

Phone 2

Present Address (Required)

City (Required)

State (Required)

Zip (Required)

Previous Address

Previous City

Previous State

Previous Zip

Email (Required)

Social Security Number (Required)

SECTION II

Position(s) Applying For

Supervising Youth in the Afterschool Program
Supervising Youth in the Summer Program
Administrative
Clerical
Building Maintenance
Bus Driving

Date available to start work (Required)

Salary/Wage Requirements (Required)

How many hours per week do you wish to work (Required)

Start time-End time

Afterschool Program operates M-F 2p-7p. Summer Program operates M-F 7a-7p. Office Hours are 10a-7p. Enter your hours of availability for each day of the week.

Monday

Start time-End time

Tuesday

Start time-End time

Wednesday

Start time-End time

Thursday

Start time-End time

Friday

Use this space to provide more details about your preferred hours and availability

Activities you are capable of supervising (Program Support Positions Only)

Gym and recreational activities
Technology activities
Arts/crafts and basic life skills activities
Homework help and educational activities
N/A (non-program support positions)

Any special training or certifications completed relevant to the position for which you are applying (including Life Guarding)?

SECTION III

Educational History

High School (Required)

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Current grade in high school (or last grade completed) (Required)

College (Required)

Degree(s) or years completed (Required)

Other

Employment Record

1. Company Name (Required)

Dates of Employment

Start Date

–

End Date

Manager/Supervisor (Required)

Company Address (Required)

Company Phone (Required)

Position(s) Held (Required)

Responsibilities (Required)

Reason for leaving (Required)

2. Company Name (Required)

Dates of Employment

Start Date

–

End Date

Manager/Supervisor (Required)

Company Address (Required)

Company Phone (Required)

Position(s) Held (Required)

Responsibilities (Required)

Reason for leaving (Required)

Non-Employment References

Names of those who have supervised you in a NON-EMPLOYMENT setting, such as teachers, coaches, Club directors, etc., are recommended. Do not include relatives, personal friends, or former employers.

1. Name (Required)

Relationship (Required)

Years known (Required)

Phone (Required)

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2. Name (Required)

Relationship (Required)

Years known (Required)

Phone (Required)

ext Extension

3. Name (Required)

Relationship (Required)

Years Known (Required)

Phone (Required)

ext Extension

SECTION IV

Criminal Offense Record

Answer the following questions completely and accurately. Any falsifications or misstatements of fact may be sufficient to disqualify you. If any doubt exists in your mind as to whether or not you were arrested or charged with a criminal offense at some point in your life or whether an offense remains on your record, you should answer "Yes". You should answer "No" only if you have never been arrested or charged, or your record was expunged by a judge's court order.

Have you ever been arrested by a law enforcement officer or otherwise charged with a criminal offense?

No
Yes (please give details of the charge(s) filed and the outcome of those charges through the court system)

A. Offense Charged

Law Enforcement Agency

Date

Location

Outcome of Case

B. Offense Charged

Law Enforcement Agency

Date

Location

Outcome of Case

Have you ever been investigated for carrying out any form of child abuse/neglect or any form of sexual abuse or otherwise charged with a criminal offense related to child abuse/neglect or sexual abuse?

No
Yes (please give details of the charge(s) filed and the outcome of those charges through the court system)

A. Offense Charged

Law Enforcement Agency

Date

Location

Outcome of Case

B. Offense Charged

Law Enforcement Agency

Date

Location

Outcome of Case

SECTION V

Disclosure Authorization and Release

Please read the following section carefully before signing this application.

I hereby consent to permit Boys & Girls Clubs of Cabarrus County to contact anyone it deems appropriate to investigate or verify any information provided by me to discuss my suitability for employment, including my background, past performance, education or related matters. I expressly give my consent to any discussions regarding the foregoing and I voluntarily and knowingly waive all rights to bring an action for defamation, invasion of privacy, or any other cause of action against anyone providing or seeking such information.

I acknowledge that I have read the above Authorization and Release, fully understand it, and voluntarily agree to its provisions.

I hereby state that all of the information I have provided on this employment application is correct to the best of my knowledge. I also agree that, if accepted for a position, I will abide by the Rules and Regulations of the Boys & Girls Club and conduct myself in a manner that is conducive to the Boys & Girls Club mission. I understand that prior to my hiring I must pass a drug test and that any failed drug test during my employment could lead to dismissal.

Signature (Required)

Date (Required)

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