Ymca Of Greater Cleveland Application Form Page 4
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6IMPORTANT! PLEASE READ BEFORE SIGNING
My signature constitutes my certification that my responses are true and complete and that I have read and understand this
paragraph. Where an item is left blank, it is because there is no information within its scope. My signature further constitutes
my authorization for the YMCA of Greater Cleveland to investigate the facts submitted and for those with relevant information,
including, but without limitation, physicians, hospitals, schools, law enforcement agencies, my prior employers and/or personal
references to provide such information to the YMCA of Greater Cleveland, and I release them from liability for doing so.
A copy of this form shall serve as my authorization to release information and records. I hereby consent to undergo such drug
screenings and post-offer medical examinations as the YMCA of Greater Cleveland may require (which may include obtaining body
tissue or fluid samples and analysis of them). I understand and agree that any falsification or omission either on this form or in
my response to questions asked during the interviewing or examination process or on employment forms I may subsequently
complete, including “I-9” forms, may result in immediate termination of employment, no matter when the falsification or omission
is discovered.
I also understand that, if hired, my employment is to be “at will” and that either I or my employer may terminate my employment at
any time, with our without cause, unless the “at will” arrangement is modified by a written agreement signed by both myself and
the President of the YMCA of Greater Cleveland.
*I also understand that if I volunteer for the YMCA of Greater Cleveland and have unsupervised access to children, I may be
required to provide a set of fingerprints and a criminal records check as required by the State of Ohio., Am.Sub.SB 187.
By typing my first and last name followed by the last four digits of my Social Security Number, I hereby agree with the
above information.
SIGNATURE:
DATE:
DO NOT WRITE BELOW THIS LINE
Interviewed by:
Date:
If applicant was previously employed at the YMCA of Greater Cleveland, are they eligible for rehire? r No r Yes
VERIFIED BY:
DATE:
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