Name(last, first, middle*

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Street Address*

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City, State, & Zip Code*

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Phone Number*

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Date you can start*

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Are you willing to volunteer for our after-school & summer camp programs?

Yes

If, So please check all that apply…

Temporary part-time work?

Part-time work?

Primary Emergency Contact:

Contact Name*

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Relationship to Contact*

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Home Telephone*

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Cellular Telephone*

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I hereby declare and certify that information written on application is true and complete to the best of my knowledge and can be used for funding purposes. *

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Signature*

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Date*

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E-mail

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Do you have a High School Diploma/GED

Are you authorized to work in the U.S.

Have you ever been convicted of a felony?

Can you perform these essentials functions of the job with or without reasonable accommodations?

Work History

Back Ground check is required

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