Name (first, middle, last) :
Social Security Number :
Phone Number #1 (xxx-xxx-xxxx) :
Phone Number #2 (xxx-xxx-xxxx) :
Email Address :
T-Shirt Size :
Permanent Address :
School Address :
Indicate dates available for employment :
What Position are you applying for?
If you are applying for a residential position, which position(s) are you most interested in?
If you are applying for a day position, which position(s) are you interested in most?
If you are applying for an Autism Day Camp position, which position(s) are you interested in most?
Emergency Contact #1 (Name, Phone #1, Phone #2, Relationship to Staff) :
Emergency Contact #2 (Name, Phone #1, Phone #2, Relationship to Staff) :
Do you currently have medical or hospitalization insurance?
If yes, please list insurance company and policy number :
Please indicate highest field of education completed :
Please list high school and beyond:
High School Attended :
Years :
Degree Granted :
School Attended :
Years :
Major/Area of Study :
Degree Granted :
School Attended :
Years :
Major/Area of Study :
Degree Granted :
Most Recent Employer
Employer :
Supervisor Name :
Position Held :
Dates of Employment (from which month/year to month/year?) :
Phone Number (xxx-xxx-xxxx) :
Address :
Reason for Leaving :
Next Most Recent Employer
Employer :
Supervisor Name :
Position Held :
Dates of Employment (from which month/year to month/year?) :
Phone Number :
Address :
Reason for Leaving :
Next Most Recent Employer
Employer :
Supervisor Name :
Position Held :
Dates of Employment (from which month/year to month/year?) :
Phone Number :
Address :
Reason for Leaving :
Please explain any gaps in employment :
PERSONAL REFERENCES: Please, do not list family members.
Reference One
Name :
Relationship to Applicant :
Phone Number (xxx-xxx-xxxx) :
Address :
Years/Months Known :
Reference Two
Name :
Relationship to Applicant :
Phone Number (xxx-xxx-xxxx) :
Address :
Years/Months Known :
Reference Three
Name :
Relationship to Applicant :
Phone Number (xxx-xxx-xxxx) :
Address :
Years/Months Known :
Please note, that in compliance with agency policy, Isanogel staff will complete a minimum of three references
Camp :
Dates :
Camp Director :
Were you a Camper or Staff?
Camp :
Dates :
Camp Director :
Were you a Camper or Staff?
Camp :
Dates :
Camp Director :
Were you a Camper or Staff?
STUDENT AND PROFESSIONAL ORGANIZATIONS
Organization One :
Dates Involved :
Location :
Organization Two :
Dates Involved :
Location :
Organization Three :
Dates Involved :
Location :
Health Safety :
Food Service :
Activity/Leadership Experience :
Dates :
Location :
Activity/Leadership Experience :
Dates :
Location :
Activity/Leadership Experience :
Dates :
Location :
Please describe any experience you have, either professionally or personally, in working with children and/or adults with disabilities.
What are your primary goals for working at Isanogel this summer?
What do you think are your greatest assets to contribute to the camp community?
What do you think are some areas that may challenge you in contributing to the camp community?
Are there any reasons you may have difficulty in performing any of the essential functions of the job for which you are applying? (i.e. working long hours, assisting campers with physical care, living in the residential setting, ect.) :
This form has been designed to strictly comply
with State and Federal fair employment practice laws prohibiting discrimination
on the basis of an applicant's age, race, creed, color, religion, disability,
national origin, sex, sexual orientation, genetic information, marital status
or family responsibilities and equally to disabled veterans and veterans of the
Vietnam
era. Questions directly or indirectly reflecting such status have been
included only where needed to determine a bona
fide occupational qualification. Such questions are appropriately noted
on the application. Not withstanding these efforts, this agency does not
assume responsibility and hereby disclaims any liability for inclusion in this
form, of any questions upon which a violation of State and Federal fair
employment practice laws may be based.
If hired, I agree to abide by all of the
agency rules and regulations and understand that, if employed, my employment
may be terminated with or without cause, and with or without notice, at any time,
at the option of either the agency or me. I further understand that no representation, whether oral or written by any
representative of the agency, at any time, can constitute a contract of
employment. I understand that the agency and all Plan Administrators
shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue,
enhance or otherwise change all policies, procedures, benefits or other terms
or conditions of employment. No agent of the agency has the authority to
enter into any agreement for employment for any specified period of time or to
make any change in any policy, procedure, benefit or other term or condition of
employment other than in a document signed by the CEO or their designee.
I
acknowledge that i have read and understand the above statements and hereby
grant permission to confirm the information supplied on this application by me.
I release from all liability anyone supplying such information and I also
release the employer from all liability that might result from making an
investigation. I understand that misrepresentation or the purposeful
omission of facts called for on this application is reason to disqualify me
from further consideration and is grounds for termination if such items are a
business necessity.
I certify that this application was completed by me and that all entries
and information in it are TRUE and COMPLETE to the best of my knowledge.
I understand that false, misleading or omitted information in my
application may result in the rejection of my application, the revocation or an
offer of employment or discharge.
Applicant's Initials :
This agency is an at-will, equal opportunity employer.
j. As part of our company policy, it is standard procedure to perform National, State and County criminal background checks on someone we are considering for employment. Would you object to such a procedure?
k. It is also standard policy to conduct background checks in the areas of Medicaid fraud, driver's record, CNA registry, sexual offenders registry and child abuse registry (for those working with under 18). Would you object to such a procedure?
l. As part of our company policy, it is standard procedure to perform National, State and County criminal background checks on someone we are considering for employment. Would you object to such a procedure?
m. It is also standard policy to conduct background checks in the areas of Medicaid fraud, driver's record, CNA registry, sexual offenders registry and child abuse registry (for those working with under 18). Would you object to such a procedure?
n. Are you legally entitled to work in the United States? If hired, verification will be required by law.
Date Cleared for Hire :
for the position of :
Reviewedby/Name :
Title :
Date :
Recommended by/Name :
Title :
Date :
Recommended by/Name :
Title :
Date :
Recommended by/Name :
Title :
Date :
Approvedby/Name :
Title :
Date :
