Ymca Of Greater Seattle - Post-Employment Information Form

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YMCA of Greater Seattle
POST-EMPLOYMENT INFORMATION FORM
Please print legibly
YOUR PERSONAL INFORMATION
Your Name:____________________________________________
Household Status____________________
(P= Domestic Partner, M = Married or S = Single)
Birth date:_______/_______/_______
Home Phone # (____)_______________
Cell Ph #(____)_____________
mm
dd
yyyy
Home/Personal E-mail Address__________________________________________________________
EQUAL EMPLOYMENT OPPORTUNITY INFORMATION (please see reverse)
Please check one: Gender
Male________
Female________
Please check one of the descriptions below corresponding to the ethnic group with which you identify (see
Race/Cultural Designations as defined by the EEOC on reverse for more information).
Hispanic or Latino(a)
White/Caucasian*
Black/African American*
Asian*
American Indian or Alaska Native*
Two or more races*
Native Hawaiian or other Pacific Islander*
*Not Hispanic or Latino
YOUR FAMILY INFORMATION – for insurance, worker’s comp and statistical purposes.
Your Spouse/Partner’s Name __________________________________ Spouse/Partner’s Birth Date __________
(if not applicable leave blank)
Names of Dependent Children
Relationship to You
Birth date
1._____________________________
___________________
______________
2._____________________________
___________________
____________
3._____________________________
___________________
_____________
Attach additional page(s) if more than 3 dependent children
YOUR EMERGENCY CONTACT INFORMATION
Contact Name:_____________________________
Relationship:_______________________
(of emergency contact to you)
Contact’s Mailing Address: ________________________________________________________________
Home Telephone: (______)___________________
Work Telephone: (______)__________________
(
of emergency contact)
(of emergency contact)
Cell Phone: (_______) ______________________
E-mail Address ___________________________
(
of emergency contact)
(of emergency contact)
LANGUAGE SKILLS
The YMCA serves diverse populations. If you are fluent in another language and are willing to assist other YMCA staff
in serving children and families by assisting with translation/interpretation needs, please indicate “yes” below, and list
the languages in which you are fluent. Your name, branch and work phone number will be included on a language
resource list available to all YMCA staff.
Yes, I will help with translation needs for the following language(s):
_____________________________________________________________________
EEO information on this form will be used for EEO-1 and diversity reporting purposes only and will be kept separate
from all other personnel records. See reverse for more information
Your Signature____________________________________
Date_______________
rev 04/08
The YMCA of Greater Seattle is an Equal Opportunity Employer Committed to Workforce Diversity

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