Staff Application Form

Full Name:*

First Name Last Name

Social Security Number:*

Address:*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone:*

Area Code Phone Number

Cell Phone:*

Area Code Phone Number

E-mail:*

DOB:*

Month Day Year

Gender:*

N/A or Unknown Male Female

Marital Status:*

Single Married Engaged Divorced Widowed Separated Partnered N/A

Are you a U.S. Citizen?*

Yes No

Are you a U.S. Permanent Resident?*

Yes No

Are you authorized to work in the U.S?*

Yes No

Do you have a disability? If yes, please explain.*

Yes No

Please explain:

Position applied for:*

Teacher Teacher’s Assistant Counselor

Employment desired (All counselors are full time):*

Full time Part time

Group Preference (Choose a number from 1-3, with 1 being the most desired):

Tiny Tots: (Age 2)

Mini Gan Izzy (Ages 3-4)

Gan Izzy (Ages 5-9)

Counselors High School Name:

High School Location:

High School Years:

Other Certifications:

Teachers/ Teacher’s Assistant High School Name:

High School Location:

High School Years:

College Name:

College Location:

College Years:

College Degree:

Graduate School Name:

Graduate School Location:

Graduate School Years:

Graduate School Degree:

Other Certifications:

Have you ever been convicted of a crime?*

No Yes, please explain:

Please explain:

Do you have a driver's license:*

Yes No

Driver's license Number:

Driver's license State:

Driver's license Expiration:

Name 1:*

Name Relationship Company

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number*

Area Code Phone Number

Name 2:*

Name Relationship Company

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number*

Area Code Phone Number

1. Name of Employer:

Supervisor:

Dates:

Job title:

Phone Number

Area Code Phone Number

E-mail

Salary:

Reason for leaving (if applicable):

List the jobs you held and duties performed:

2. Name of Employer:

Supervisor:

Dates:

Job title:

Phone Number

Area Code Phone Number

E-mail

Salary:

Reason for leaving (if applicable):

List the jobs you held and duties performed:

3. Name of Employer:

Dates:

Supervisor:

Job title:

Phone Number

Area Code Phone Number

E-mail

Salary:

Reason for leaving (if applicable):

List the jobs you held and duties performed:

Details:

If you are not available for the entire summer, please indicate what dates you are available for work.

Please fill out and print W-9: Click here
* This form must be filled in and turned in upon being hired, before you begin working. Otherwise, salary will not be compensated.

Contact Information:

Employment

Criminal History

References: