YMCA OF MUNCIE EMPLOYMENT APPLICATION

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1 YMCA OF MUNCIE EMPLOYMENT APPLICATION Thank you for your interest in the YMCA! The YMCA is an equal opportunity employer and does not discriminate in recruitment, hiring or other terms or conditions of employment on the basis of race, color, religion, national origin, sex, disability, age or any other status protected by law. If you would like to apply to join the YMCA staff team, please complete the application below. Be sure to write legibly The application must be completed in full. Do not leave any spaces blank or write see resume in response to any question. Read and sign the last page of the application. Personal Information Position Applying For: Date: Preferred YMCA Location: Date Available: NAME: Last First MI Address: Street City State ZIP Telephone: Home / Business / Mobile / Are you 21 years of age or older? (If not, you may be required to provide work authorization.) Yes If hired, can you provide verification of your legal right to work in the United States? Yes Can you perform the essential functions of the job for which you are applying, with or without reasonable accommodation? Have you ever been convicted of a crime, pled no contest, or had adjudication withheld? If yes, please provide a date, location, charges and a complete explanation of all offenses. (A conviction will not necessarily bar employment. The YMCA may consider the nature, date and circumstances of the offenses.) No No Yes No Yes No 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. OFFENDERS AGAINST CHILDREN - At the YMCA, we consider it of great importance to provide a safe environment for our members, program participants and guests. For this reason, the YMCA uses its best efforts to exclude "offenders against children" or "sexually violent predators" as defined under Indiana law, from YMCA membership, program participation, facility access, volunteer opportunities or employment opportunities.

2 YMCA of Muncie Employment Application Employment Information List available days/hours: Sunday Monday Tuesday Wednesday Thursday Friday Saturday Preferred Job Status: Full-time Part-time Seasonal As Needed Have you previously been employed by this YMCA or any other YMCA? Yes No If yes, when? At which locations? Have you previously volunteered at this YMCA or any other YMCA? Yes No If yes, when? At which locations? Do you have any relatives or household members currently working for this YMCA? Yes No If yes, name(s) and relationship: How did you hear about this opening? YMCA staff referral YMCA member Name of referral source: School Advertisement Walk-in Other YMCA website Education & Training Educational Background Name of School City, State Diploma Awarded Degree Major High School GED College Graduate School Yes No In Progress Yes No In Progress Yes No In Progress Vocational/ Other Yes No In Progress Describe any non-employment experience such as school or volunteer activities that might strengthen your application: Safety & Job Specific Certifications Type (CPR, First Aid, CDA, etc.) Provider Level Expiration The Y: We re for youth development, healthy living, and social responsibility.

3 YMCA of Muncie Employment Application Employment History Employer Address Job Title List all previous employment during the past seven years starting with the most recent. Use additional sheets if needed. Telephone Dates Employed Summarize the nature of the work / From: / performed and job responsibilities. To: / Starting Hourly Immediate Supervisor and Title Reason for Leaving May we contact this employer? Yes No Telephone Employer / Address Job Title Immediate Supervisor and Title Reason for Leaving May we contact this employer? Yes No Telephone Employer / Address Job Title Immediate Supervisor and Title Reason for Leaving May we contact this employer? Yes No Telephone Employer / Address Job Title Immediate Supervisor and Title Reason for Leaving May we contact this employer? Yes No Please explain any gaps in your employment history. Ending Hourly Dates Employed From: / To: / Starting Hourly Ending Hourly Dates Employed From: / To: / Starting Hourly Ending Hourly Dates Employed From: / To: / Starting Hourly Ending Hourly Summarize the nature of the work performed and job responsibilities. Summarize the nature of the work performed and job responsibilities. Summarize the nature of the work performed and job responsibilities. What other business experience, personal experience or training have you had that may have prepared you for this position? The Y: We re for youth development, healthy living, and social responsibility.

4 YMCA of Muncie Employment Application Personal References Name: Occupation: One reference should be a family member. Years Known: Address: City: State: Zip: Phone: / Alternate #: / Name: Occupation: Years Known: Address: City: State: Zip: Phone: / Alternate #: / Name: Occupation: Years Known: Address: City: State: Zip: Phone: / Alternate#: / Application Acknowledgement and Authorization 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. Signature: Date: The Y: We re for youth development, healthy living, and social responsibility.

5 YMCA of the USA Child Abuse Prevention Training for Front-Line Staff Handout 10 Code of Conduct (for YMCA Staff & Volunteers) 1. To protect YMCA staff, volunteers, and program members, at no time during a YMCA program may a staff person be alone with a single child where he or she cannot be observed by others. As staff supervise children, they should space themselves in such a way the other staff can see them. 2. Staff shall never leave a child unsupervised. 3. Restroom supervision: Staff will make sure that the restroom is not occupied by suspicious or unknown individuals before allowing children to use the facilities. Staff will stand in the doorway of the restroom while children are using the restroom. This policy allows privacy for the children and protection for the staff (not being alone with child). If staff is assisting younger children, doors to the facility must remain open. No child, regardless of age, should ever enter a bathroom alone on a field trip or at other off-site location. Always send children in threes (known as the rule of three), and whenever possible, with staff. 4. Staff should conduct or supervise private activities in pairs diapering, putting on bathing suits, taking showers, and so on. When this is not feasible, staff should be positioned so that they are visible to others. 5. Indiana law requires the reporting of suspected abuse and neglect. According to the Indiana State Code for Child Abuse, a person commits a class B misdemeanor when he knowingly fails to make a report of child abuse or neglect. Any staff who has seen a child be abused or neglected OR has received a disclosure from a child regarding child abuse or neglect, should report to the local DCS immediately. The following actions should take place when reporting child abuse or neglect: Documentation of the witnessed or disclosed child abuse or neglect; include report date, eyewitness observations, and/or direct conversations. Also include name of child/children, ages of each child, address, and phone number. Contact direct supervisor to inform them of the situation. A supervisor will sit with any staff uncomfortable calling DCS. 6. Whistle Blower Rule: Staff who report any suspected child abuse can remain anonymous and are immune from all civil and criminal liability, provided they have made the report in good faith. 7. Staff shall not abuse children in any way, including Physical abuse striking, spanking, shaking, slapping, and so on; Verbal abuse humiliating, degrading, threatening, and so on; Sexual abuse touching, or speaking inappropriately; Mental abuse shaming, withholding kindness, being cruel; Neglect withholding food, water, or basic care. No type of abuse will be tolerated and may be cause for immediate dismissal. 8. Any staff member who is accused of abuse or neglect of a child in the program, their rights will be protected during the investigation proceedings. The staff member will be suspended until the

6 investigation clears the accused staff member. All children in the program are protected from the accused staff member due to suspension until all investigations clear the accused staff member of all allegations. 9. Staff must use positive techniques of guidance, including redirection, positive reinforcement, and encouragement rather than competition, comparison, and criticism. Staff will have age-appropriate expectations and set up guidelines and environments that minimize the need for discipline. Physical restraint is used only in predetermined situations (when necessary to protect the child or other children from harm), administered only in a prescribed manner, and must be documented in writing. 10. Staff will conduct a health check of each child upon his or her arrival each time the program meets, noting any fever, bumps, bruises, and so on. Questions or comments will be addressed to the parent or child in a non-threatening way. Staff will document and questionable marks or responses. 11. Staff will respond to children with respect and consideration and treat all children equally, regardless of sex, race, religion, culture, economic level of the family, or disability. 12. Staff will respect children s rights not to be touched or looked at in ways that make them feel uncomfortable, and their right to say no. Other than diapering, children are not to touched on areas of their bodies that would be covered by a bathing suit. 13. Staff will refrain from intimate displays of affection toward others in the presence of children, parents, and staff. 14. Staff is not to transport children in their own vehicles or allow youth participants old enough to drive to transport younger children in the program. 15. Staff must appear clean, neat, and appropriately attired. 16. Using, possessing, or being under the influence of alcohol or illegal drugs during working hours is prohibited. 17. Smoking or use of tobacco in the presence of children or parents during working hours is prohibited. 18. Possession or use of any type of weapon or explosive device is prohibited. 19. Using YMCA computers to access pornographic sites, send s with sexual overtones or otherwise inappropriate messages, or develop online relationships is not allowed. 20. Profanity, inappropriate jokes, sharing intimate details of one s personal life, and any kind of harassment in the presence of children, parents, volunteers, or other staff is prohibited. 21. Staff may not be alone with children they meet in YMCA programs outside the YMCA. This includes babysitting, sleepovers, driving, or riding in cars, and inviting children to their homes. Any exceptions require a written explanation before the fact and are subject to prior administrator approval. 22. Staff must be free of physical or psychological conditions that might adversely affect children s physical or mental health. If in doubt, an expert should be consulted.

7 23. Staff will portray a positive role model for youth by maintaining an attitude of loyalty, patience, courtesy, tact, and maturity. 24. Staff should not give excessive gifts (e.g., TV, video games, jewelry) to youth. 25. Staff may not date program participants who are under the age of Under no circumstances should staff release children to anyone other than the authorized parent, guardian, or other adult authorized by the parent or guardian (written parent authorization on file with the YMCA). 27. Staff is to report to a supervisor any other staff or volunteer who violates any of the policies listed in the Code of Conduct. 28. Staff is required to read and sign all policies related to identifying, documenting, and reporting child abuse and attend trainings on the subject, as instructed by a supervisor. 29. Staff will act in a caring, honest, respectful, and responsible manner consistent with the mission of the YMCA. I understand that any violation of this Code of Conduct may result in termination. Employee or volunteer signature Date Supervisor or CAP Trainer Signature Date Revision 10/2009

8

9 YMCA of Muncie Illicit Substance Screening Requirements It is the policy of the YMCA of Muncie that all applicants being considered for employment, or current employees, be willing to successfully complete a substance screening test upon request. The presence of illicit drugs, other than those prescribed by a physician, will be measured by urinalysis if you are asked to participate. The positive presence of these drugs reported in your drug testing release form may be grounds for refusal of employment or dismissal. Each applicant or employee is required to fill out this form. Applicant Substance Testing Release I, (name of employee/applicant), voluntarily authorize Pathologists Associated, its physicians and its employees to take specimens of my urine and to perform a urine test designed to detect the presence of illicit drugs (amphetamine, barbiturate, benzodiazepines, cannabinoids, cocaine, opiates, or phencyclidine) or any other substances, which can impair my alertness. Further, I voluntarily authorize Pathologists Associated, its physicians and its employees to disclose the test results to my employers, the YMCA of Muncie, or its representatives. I hereby state that I am taking or have been prescribed by a physician and am currently taking the following medications (if none, state none ): Non-Prescription Prescription I further agree not to hold Pathologists Associated, its physicians, and/or its employees liable for disclosure to the YMCA of Muncie or any results relating to this release. Signature of Applicant Date Time Witness

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