For DIRECT CARE STAFF ONLY (Days & Shifts Available to Work)

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1 Date: Position Applied For: Referred By: Full Time Part Time Temporary Seasonal Internship Other Name: Social Security Number: Address: City: State: Zip: Home Phone: Cell Phone: 1. If you are under 18, can you furnish working papers?.. Yes No 2. Have you ever filed an application here before? Yes No If yes, give date: 3. Have you ever been employed here before? Yes No If yes, give dates: to 4. Have you ever volunteered here before?.. Yes No If yes, give dates: to 5. Are you a relative (through a blood-relationship or an in-law) of any Ohel Bais Ezra Board members or employees? Yes No If yes, please indicate the name(s) of the Board member or staff and the nature of your relationship with them (son, first cousin...): 6. Are you legally eligible for employment in this country?.. Yes No 7. Have you ever been convicted of a felony or a misdemeanor in any jurisdiction?. Yes No 8. Is there a pending criminal charge against you in any jurisdiction?.. Yes No Please provide a description of the conviction or pending criminal charge 9. Have you ever been excluded from participation in Medicare, Medicaid, or any Yes No other government or other health care program? If yes, please describe: Do you have a current driver s license? Yes No State: Are you willing to drive if required by the position applied for? (A) Have you had any moving violations or convictions related to moving violations within the last three years? Yes No (B) Have you ever had a suspension, revocation, DWI conviction, or any occurrence involving harm to persons or property while driving? Yes No If you answered YES to either (A) or (B), please provide details below: For DIRECT CARE STAFF ONLY (Days & Shifts Available to Work) Part Time or Full Time Part Time or Full Time Part Time Weekends Summer Only 3:00 PM 11:00 PM 11:00 PM 7:00 AM Friday 2:00 PM to Sunday 2:00 PM July - August Sunday Thursday Sunday - Thursday Camp S M T W Th S M T W Th # of weekends per month: City Available Only:

2 EDUCATIONAL INFORMATION School Name and Address Years Completed Degree/Diploma WORK HISTORY * Please list your last three (3) employers, last job first and state the reasons for leaving. * Employer / Company Name Dates Employed Salary Address/ Phone Job Title/ Description & Reason for Leaving Supvsr. Name May we contact the above named for work related references? Yes [ ] No [ ] REFERENCES Please list three (3) business or personal references who are not relatives or friends. Name Phone Years Known Please list any additional experience or knowledge you may have with the disabled population or skills.

3 APPLICANT S AFFIDAVIT I certify that the information contained herein is true and correct to the best of my knowledge. I authorize investigation of all matters contained herein and agree that any misleading or false statements or subsequently discovered material omissions would be cause for non-employment or immediate dismissal after employment. I understand that my employment is contingent upon receipt by Ohel Children s Home & Family Services/Bais Ezra Community Residences of satisfactory references, my successful completion of the introductory probation period and whatever clearances are required for my position. I acknowledge that Ohel/Bais Ezra requires applicants to undergo a physical examination as part of the pre-employment screening process and that successful completion of it is also a requirement for employment. I agree if I am employed, to furnish Ohel/Bais Ezra with such verification as permitted under NY law including proof of citizenship and/or ability to hold US employment and agree to abide by all Ohel/Bais Ezra regulations and policies, current and as revised from time to time. I further acknowledge that this application is not a contract of employment and that initial employment is not a guarantee of continued or ongoing employment. I understand that my employment may be terminated at any time by Ohel Bais Ezra with or without cause or notice. I also understand that any agreement contrary to the foregoing must be in writing and signed by the Executive Director. SIGNATURE DATE NAME OF APPLICANT (Please Print) For HR Office use Only Forwarded: Position: DO NOT WRITE BELOW THIS LINE Date: Department: Availability: S M T W T F Comments: Typed WPM Overall Rating A B C D

4 lnvestigative REQUEST FOR EMPLOYMENT DATA AND SUPERVISOR INFORMATION * FOR OFFICE USE ONLY * TO: Company: Dept/Contact: Address: City: State: ZIP: Your name has been provided by the person identified below to assist us in completing a background investigation which will help us determine this person s suitability for employment. To help us make this determination, we ask that you complete all items on the attached form and return it in the enclosed envelope. The information you provide, including your identity, will be disclosed to the person being investigated on this person s request, unless you ask that your identity be kept confidential. The person we are investigating has signed the consent below, for this background. ================================================================================ * APPLICANT, PLEASE READ & SIGN * INVESTIGATIVE REQUEST FOR EMPLOYMENT CONSENT FORM I hereby authorize release of background information as requested by Ohel/Bais Ezra and agree to hold harmless Ohel/ Bais Ezra and the respondent to this investigation for providing this information. Signature of Applicant Date Name Of Applicant (Please Print)

5 OHEL CHILDREN S HOME AND FAMILY SERVICES (also doing business as BAIS EZRA) FAIR CREDIT REPORTING ACT: DISCLOSURE AND AUTHORIZATION STATEMENT TO: ALL EMPLOYEES PLEASE READ CAREFULLY BEFORE SIGNING BELOW I understand that the agency may obtain or have prepared a consumer or investigative consumer report for employment purposes, concerning my prior employment, motor vehicle record, military record, education, general reputation, personal characteristics, or criminal background. I understand that upon request to the agency, I will be informed of whether a consumer report was requested and, if so, the name and address of the consumer reporting agency that furnished the report. I understand that upon written request to the agency, I will be informed whether an investigative consumer report was requested, and given full information as to the nature and scope of this investigation. (I understand that an investigative consumer report is a report in which information concerning my character, general reputation, personal characteristics, or mode of living, is obtained through personal interviews with neighbors, friends, or associates with whom I am acquainted.) I authorize the agency to obtain additional consumer or investigative consumer reports on me for employment purposes at any time during my employment. By my signature below, I also acknowledge that the agency has provided me with a summary of my rights under the federal Fair Credit Reporting Act. NAME OF APPLICANT (PLEASE PRINT) SIGNATURE OF APPLICANT DATE SIGNED

6 Please take a moment to answer a few questions: Today s date What position are you applying for? How did you learn of this opening? Newspaper ad (which newspaper?) On line posting (which website?) Ohel Bais Ezra website Ohel Bais Ezra employee Job Developer (please state name) Recruiter in Israel Other Thank you. PLEASE FAX APPLICATION TO: INQUIRIES: TELEPHONE: WEB: CampKaylie.org

7 This Section for Applicant to Keep A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every consumer reporting agency (CRA). Most CRAs are credit bureaus that gather and sell information about you such as if you pay your bills on time or have filed bankruptcy to creditors, employers landlords, and other businesses. You can find the complete text of the FCRA, 15 U.S.C u, at the Federal Trade Commission s web site ( The FCRA gives you specific rights, as outlined below. You may have additional rights under state law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights. You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action against you such as denying an application for credit, insurance, or employment must tell you, and give you the name, address, and phone number of the CRA that provided the consumer report. You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by the CRA, if you request the report within 60 days of receiving notice of the action. You also are entitled to one free report every twelve months upon request if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars. You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless your dispute is frivolous. The source must review your evidence and report its findings to the CRA. (The source also must advise national CRAs to which it was provided the data of any error.) The CRA must give you a written report of the investigation, and a copy of your report if the investigation results in any change. If the CRA s investigation does not resolve the dispute, you may add a brief statement to your file. The CRA must normally include a summary of your statement in future reports. If an item is deleted or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change. Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a written notice telling you it has reinserted the item. The notice must include the name, address and phone number of the information source. You can dispute inaccurate items with the source of the information. If you tell anyone such as a creditor who reports to a CRA that you dispute an item, they may not then report the information to a CRA without including a notice of your dispute. In addition, once you ve notified the source of the error in writing, it may not continue to report the information if it is, in fact, an error. Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven years old; ten years for bankruptcies. Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCRA usually to consider an application with a creditor, insurer, employer, landlord, or other business.

8 Your consent is required for reports that are provided to employers, or reports that contain medical information. A CRA may not give out information about you to your employer, or prospective employer, without your written consent. A CRA may not report medical information about you to creditors, insurers, or employers without your permission. You may choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors and insurers may use file information as the basis for sending you unsolicited offers of credit or insurance. Such offers must include a toll-free phone number for you to call if you want your name and address removed from future lists. If you call, you must be kept off the lists for two years. If you request, complete, and return the CRA form provided for this purpose, you must be taken off the lists indefinitely. You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data, violates the FCRA, you may sue them in state or federal court. The FCRA gives several different federal agencies authority to enforce the FCRA: FOR QUESTIONS OR CONCERNS REGARDING: CRAs, creditors and others no listed below National banks, federal branches/agencies of foreign banks (word National or initials N.A. appear in or after bank s name) Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks) Savings associates and federally chartered savings banks (word Federal or initials F.S.B. appear in federal institution s name) Federal credit unions (words Federal Credit Union appear in institution s name) State-chartered banks that are not members of the Federal Reserve System PLEASE CONTACT: Federal Trade Commission Consumer Response Center FCRA Washington, DC (202) Office of the Controller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC (800) Federal Reserve Board Division of Consumer & Community Affairs Washington, DC (202) Office of Thrift Supervision Consumer Programs Washington, DC (800) National Credit Union Administration 1775 Duke Street Alexandria, VA (703) Federal Deposit Insurance Corporation Division of Compliance & Consumer Affairs Washington, DC (800)

9 CAMP KAYLIE STAFF REFERENCE FORM #1 Name: Position Seeking: I give permission to (Applicant Name) To be completed by Applicant (Reference Name) provide information requested on this reference form to Camp Kaylie. I understand that it will become part of my personnel file and that all information will be held in strict confidence. Applicant s signature: Date: / / To be completed by reference: Please fill out the area below and on the following page. The applicant is applying to work at Camp Kaylie, a summer camp for children of all abilities. Name: Title: How long have you known this applicant? In what capacity? Please check the appropriate categories based on your knowledge of the applicant. If you do not have ample information please check unknown. ATTRIBUTES UNKNOWN ABOVE AVERAGE BELOW POOR AVERAGE AVERAGE Attitude Cooperation Reliability Enthusiasm Appearance Initiative Maturity Concern for Others Responsibility Integrity Sociability Flexibility

10 The applicant will likely work with individuals who have special needs. Do you have any hesitations? Yes No If yes, please explain: May we contact you for additional information? Yes No Additional Comments: Reference Signature Phone # ( ) Date Form Completed / / Thank you for your assistance! Please either return to the applicant in a sealed envelope or send directly to the camp office at: Fax: (718)

11 CAMP KAYLIE STAFF REFERENCE FORM #2 Name: Position Seeking: I give permission to (Applicant Name) To be completed by Applicant (Reference Name) provide information requested on this reference form to Camp Kaylie. I understand that it will become part of my personnel file and that all information will be held in strict confidence. Applicant s signature: Date: / / To be completed by reference: Please fill out the area below and on the following page. The applicant is applying to work at Camp Kaylie, a summer camp for children of all abilities. Name: Title: How long have you known this applicant? In what capacity? Please check the appropriate categories based on your knowledge of the applicant. If you do not have ample information please check unknown. ATTRIBUTES UNKNOWN ABOVE AVERAGE BELOW POOR AVERAGE AVERAGE Attitude Cooperation Reliability Enthusiasm Appearance Initiative Maturity Concern for Others Responsibility Integrity Sociability Flexibility

12 The applicant will likely work with individuals who have special needs. Do you have any hesitations? Yes No If yes, please explain: May we contact you for additional information? Yes No Additional Comments: Reference Signature Phone # ( ) Date Form Completed / / Thank you for your assistance! Please either return to the applicant in a sealed envelope or send directly to the camp office at: Fax: (718)

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