YMCA of Greater Grand Rapids

Corporate Office
475 Lake Michigan Drive
Grand Rapids, MI 49504
Phone: 616-855-9600
Fax: 616-855-9601

Employment Application

Personal Information


First Name


Middle Name


Last Name

Phone Number

Email Address
     


Home Address


City


State

ZIP Code


Address while at School


City


State

ZIP Code

Military Service:

Yes No


From
To


Rank

Have you ever been convicted of a felony?
Yes No

Are you legally eligible for employment in the United States?

Yes No

Have you ever been convicted of child abuse?
Yes No
If yes, explain:

Are you at least 18 years old? Yes No
Have you ever worked for this YMCA previously? Yes No If yes, branch:
Have you ever worked for this YMCA under a different name? Yes No
If yes, name:

Please enter any additional information relative to change of name, use of an assumed name or nickname necessary to enable a check on your work record.

Work Desired


First Choice


Full/Part Time


Years of Exp.


Wages Expected


Second Choice

Full/Part Time

Years of Exp.

Wages Expected

Availability for Work
What date are you available for work?
What hours are you available for work? (Please note hours available and hours unavailable to work in table below.)
Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Available
Not Available

Education and Skills
Type of School
Name and Address of School
Course Majored
GPA
Graduated
High School
College
Other
Computer Skills Personal Computer: Typing:

WPM:
  Spreadsheet: Database:  

Please list software packages in which you are experienced:

Early Childhood Courses Completed:
 Number of Units:
Course Title/Subject:

Current Certifications
Fitness 
Aquatic 
Other
Y's WAY TO
Type
Exp. Date
Type
Exp. Date
Physical Fitness Leader
YMCA Lifeguarding/or other
CPR
Physical Fitness Specialist
YMCA Swim Instructor/or other
First Aid
Physical Fitness Instructor
YMCA Lifeguard Instructor/or other
Weight Management Instructor

Healthy Back Instructor

Other:

Other Aquatics Certifications:

  

YMCA
Why do you desire to work in the YMCA?
Describe any YMCA, Community Agency and/or other volunteer experience you have had:
What do you feel qualifies you for this position?
Would you be willing to continue your education by enrolling in certain courses or training programs that may be recommended?

Health

List any health problems, illness or injuries you have or have had that would affect your ability to do the work for which you are applying:
Have you received Worker's Compensation Benefits? Yes No

If yes, please describe:
In case of emergency contact:
Phone number:

Work Experience

Present or Last Employer:

 Address:
 Phone Number:
Supervisor's Name:
Job Title:

Work Performed:
Date Hired: (mm/yy)

 Date Left: (mm/yy)
 Final Salary:
 Reason for Leaving:

Second Employer:

 Address:
 Phone Number:
Supervisor's Name:
Job Title:

Work Performed:
Date Hired: (mm/yy)

 Date Left: (mm/yy)
 Final Salary:
 Reason for Leaving:

Third Employer:

 Address:
 Phone Number:
Supervisor's Name:
Job Title:

Work Performed:
Date Hired: (mm/yy)

 Date Left: (mm/yy)
 Final Salary:
 Reason for Leaving:

Other Skills - Talents
Driver's License Number:
 Driver's License Classification:
List any machines you can operate, clerical or mechanical:
List any special skills or talents:
List any membership in any professional organizations that you feel would be relevant to your ability to perform the job:

YMCA OF GREATER GRAND RAPIDS PRE-EMPLOYMENT REFERENCE CHECK
Date: Company: Address:
City: State: ZIP Code:
Telephone Number: Fax Number:
Name of Applicant:
Relationship to Applicant:
Dates of Employment From:
To:
 Supervisor's Name:
Name of Position: Reason for Leaving:
I have applied for an employment/volunteer opportunity with the YMCA. Please complete this reference and return. Thank you.

I hereby authorize persons, schooles, my current employer (if applicable), and previous employers and other organizations to provide the YMCA of Greater Grand Rapids with any requested information regarding my application or suitability for employment.
Signature of Applicant: Date:
*APPLICANT - Please do not write below this line.*
Please verify the information above and complete the following:

Is the information provided correct? Yes No If no, what is incorrect? _________________________
Would you rehire or recommend this applicant for employment? Yes No If no, why? __________________________________
Do you have any reason to believe this individual presents any danger to him/herself or others? Yes No
If yes, why? ___________________________________________________________________________

How would you rate the applicant's performance in the following areas? Please circle appropriate number
( 1 = Outstanding, 2 = Very Good, 3 = Good, 4 = Needs Improvement, 5 = Unsatisfactory, 6 = Unable to respond)
Attendance 1 2 3 4 5 6 Productivity 1 2 3 4 5 6 Work Quality 1 2 3 4 5 6
Cooperation 1 2 3 4 5 6 Job Knowledge 1 2 3 4 5 6 Communication 1 2 3 4 5 6
Initiative 1 2 3 4 5 6 Reliability 1 2 3 4 5 6 Creativity 1 2 3 4 5 6
Adherence to Policies 1 2 3 4 5 6 Resepect from Others 1 2 3 4 5 6 Ability to work Independently 1 2 3 4 5 6
Team Work 1 2 3 4 5 6 Comments: _________________________________________________
_________________________________________
Name of Individual Providing Reference (please print)		 __________________________________________
Signature
_________________________________________
Title / Department		 ____________________
Date

YMCA OF GREATER GRAND RAPIDS PRE-EMPLOYMENT REFERENCE CHECK
Date: Company: Address:
City: State: ZIP Code:
Telephone Number: Fax Number:
Name of Applicant:
Relationship to Applicant:
Dates of Employment From:
To:
 Supervisor's Name:
Name of Position: Reason for Leaving:
I have applied for an employment/volunteer opportunity with the YMCA. Please complete this reference and return. Thank you.

I hereby authorize persons, schooles, my current employer (if applicable), and previous employers and other organizations to provide the YMCA of Greater Grand Rapids with any requested information regarding my application or suitability for employment.
Signature of Applicant: Date:
*APPLICANT - Please do not write below this line.*
Please verify the information above and complete the following:

Is the information provided correct? Yes No If no, what is incorrect? _________________________
Would you rehire or recommend this applicant for employment? Yes No If no, why? __________________________________
Do you have any reason to believe this individual presents any danger to him/herself or others? Yes No
If yes, why? ___________________________________________________________________________

How would you rate the applicant's performance in the following areas? Please circle appropriate number
( 1 = Outstanding, 2 = Very Good, 3 = Good, 4 = Needs Improvement, 5 = Unsatisfactory, 6 = Unable to respond)
Attendance 1 2 3 4 5 6 Productivity 1 2 3 4 5 6 Work Quality 1 2 3 4 5 6
Cooperation 1 2 3 4 5 6 Job Knowledge 1 2 3 4 5 6 Communication 1 2 3 4 5 6
Initiative 1 2 3 4 5 6 Reliability 1 2 3 4 5 6 Creativity 1 2 3 4 5 6
Adherence to Policies 1 2 3 4 5 6 Resepect from Others 1 2 3 4 5 6 Ability to work Independently 1 2 3 4 5 6
Team Work 1 2 3 4 5 6 Comments: _________________________________________________
_________________________________________
Name of Individual Providing Reference (please print)		 __________________________________________
Signature
_________________________________________
Title / Department		 ____________________
Date

Applicant Authorization and Release

Please read the following statement carefully before signing to indicate your understanding.

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.

I hereby authorize persons, schools, or current employer (if applicable) and previous employers and other organizations to provide the Grand Rapids Metropolitan YMCA with any lawful information regarding my application or suitability for employment and I completely release all such persons or entities from any and all liability related to providing or use of any such lawful information.

I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the YMCA has the same right.
Applicant's Signature:
Date: