Application For Volunteer Service At The Palestine Ymca Form Page 2
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5Employment History
Please list your current employer:
Name of organization: ____________________________________________________________________________
From when to when? _________________________ Job title: ____________________________________________
Describe work: __________________________________________________________________________________
Name and title of immediate supervisor: ______________________________________________________________
References
Please list three people besides relatives and employers whom you have known for at least two years and who know
you well enough to provide with a reference.
1. Name: _____________________________________________________________________________________
Address: ____________________________ City: __________________ State: ________ Zip: _______________
Phone: ____________________ Relationship to you: _______________
______
How long have you know this reference?
2. Name: _____________________________________________________________________________________
Address: ____________________________ City: __________________ State: ________ Zip: _______________
Phone: ____________________ Relationship to you: _______________
______
How long have you know this reference?
3. Name: _____________________________________________________________________________________
Address: ____________________________ City: __________________ State: ________ Zip: _______________
Phone: ____________________ Relationship to you: _______________
______
How long have you know this reference?
Please list the names of relatives, friends, or acquaintances employed by the YMCA and their relationship to you.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Background
Please list here any other names you may have used in the past: ___________________________________________
______________________________________________________________________________________________
Date of Birth: _______________ Driver’s license number: _________________________ Classification: A B C M
Have you ever been convicted of a criminal offense? __________ If so, what was it? ___________________________
______________________________________________________________________________________________
How long at current address? _________________________ Social Security number:________-_________-________
Residents
Please list your last two addresses (excluding you current address) starting with the most recent:
1. __________________________________________________ From when to when? _________________________
2. __________________________________________________ From when to when? _________________________
As a condition of volunteering, I give permission for The Palestine YMCA and its assigned agencies to conduct a background check on
me, which may include a review of criminal records maintained by government agencies. I understand that my position is dependent
upon receiving no inappropriate information on my background check. I am subject to suspension by the YMCA at anytime in the event
of inappropriate behavior as outlined in the Volunteer Code of Ethics and Rules. The facts set forth in my application are true and
complete. I understand that if engaged, false statements on this application will be considered sufficient cause for dismissal.
Signature: ____________________________________________ Date: _________________
Parent or guardian’s signature ____________________________ Date: __________________
(If you are under 18)
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Parent category: Business