Five Star Life Application 2020-2021

Five Star Life/Summit Application

2020-2021
Select Type of Application *

Basketball Coach Application Coach/Volunteer Application Job Application
Date of Basic Training
Date of Predator Training
Number of References Submitted
Full Name *

First Name Middle Name Last Name
Today's Date

Month Day Year
Date
Have you submitted a Five Star Life Application before? *

Yes No
Birth Date *

Month Day Year
Calculation
Gender *
E-mail *
Phone Number *
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Phone Number *
Parent/Guardian E-mail *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Employer Name *
Emergency Contact #1 *
Emergency Contact #1 Relationship to you *
Emergency Contact #1 Phone Number *
Emergency Contact #2 *
Emergency Contact #2 Relationship to you *
Emergency Contact #2 Phone Number *
Education
What is your highest level of education? *
What year did you graduate or do you plan to graduate? *
What did you study? *
What school did you attend for your highest education? *
City and State for Highest Education *
Previous Employment
Name of Most Recent Employer *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
Starting Date *

Month Day Year
Ending Date *

Month Day Year
Salary *
Do you have another employer to list? *

Yes No
Name of Employer #2 *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
Starting Date *

Month Day Year
Ending Date *

Month Day Year
Salary *
Do you have another employer to list? *

Yes No
Name of Employer #3 *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
Starting Date *

Month Day Year
Ending Date *

Month Day Year
Salary *
References

List at least three adults you have known for at least one year, who are not related to you or Five Star Life employees and have a definite knowledge of your character and ability to work with students.
Reference #1 Name *

First Name Last Name
Reference #1 Phone Number *
Reference #1 E-mail *
example@example.com
Reference #2 Name *

First Name Last Name
Reference #2 Phone Number *
Reference #2 E-mail *
example@example.com
Reference #3 Name *

First Name Last Name
Reference #3 Phone Number *
Reference #3 E-mail *
example@example.com
Reference #4 Name

First Name Last Name
Reference #4 Phone Number
Reference #4 E-mail
example@example.com
Please select the area(s) of interest *

Facility Care Nature Education Grounds Care Equine Hospitality Team High Ropes (Rock Wall & Team Building) Event Host Photography or Videography Coach Five Star Art Archery Health Officer Lifeguard Five Star Life Intern Job Basketball
Click here for brief description of volunteer oppotunities.
What position are you applying for? *
Type of Employment Desired *

Full-Time Part-Time
What size T-shirt do you wear? *
Please list any experience you have Coaching Basketball. *
Why do you want to be a volunteer for Five Star Life? *
Five Star Life Volunteers You Know
Please state why you are qualified for this position. *
What skills do you have that will benefit you in this position? *
If hired, can you provide proof you are eligible to work in the U.S.? *

Yes No
Do you have an active checking account (for payroll deposits)? *

Yes No
Integrity - who you are when no one is looking...the real you *

Excellent Good Needs Improvement
Respect - treat others the way you want to be treated *

Excellent Good Needs Improvement
Responsibility - taking ownership of your past choices, current reality and future dreams *

Excellent Good Needs Improvement
Courage - the strength to do what is right over what is popular *

Excellent Good Needs Improvement
Sacrifice - giving up something now for something greater later or giving up something you want in order to help someone else win *

Excellent Good Needs Improvement
Initiative - the power or opportunity to act or take charge before others do *

Excellent Good Needs Improvement
Commitment - devoted to a task or purpose *

Excellent Good Needs Improvement
Communication - interchange of thoughts, opinions, or information by speech, writing, or signs *

Excellent Good Needs Improvement
Coachable - willing to be pushed to be improved *

Excellent Good Needs Improvement
Team Participation - thrives in various and diverse environments *

Excellent Good Needs Improvement
Personal History
Five Star Life/Summit

Disclosure Form - Five Star Life and Summit cares about the children and youth in our programs and desires to ensure their safety while they are in our supervision. Because we care for children and youth, our organizations join in asking any new staff member or volunteer who will be interacting with children and/or youth, to complete this disclosure form. Please complete the following questions by circling the appropriate response. Please attach an explanation for any "yes" answer.
1. Have you ever been treated for a psychiatric disorder? *
Please explain. *
2. Have you ever been arrested, convicted, or pleaded guilty to a crime? *
Please explain. *
3. Have you ever been accused, charged, or alleged to have, or have you ever committed any act of neglecting, abusing, or molesting any child? *
Please explain. *
4. Have you ever been concerned that you may have an addiction to drugs, alcohol, or pornography;or has anyone ever suggested that you may have a problem with any of the above? *
Please explain. *
5. Have you been convicted of the possession, use, or sale of drugs within the last seven years? *
Please explain. *
6. Have you been released from incarceration for a conviction of the possession, use, or sale of drugs within the last seven years? *
Please explain. *
7. Within the past 30 days have you abused alcohol, legal or illegal drugs? *
Please explain. *
8. Has your driver’s license been suspended or revoked within the last seven years? *
Please explain. *
9. Is there any fact, circumstance, or pattern involving your background that would make it inappropriate for you to serve with minors or would compromise the integrity of the Five Star? *
Please explain. *
List all previous work involving children (organization name, city, state, type of work) *
Health History
NOTE: All PARTICIPANTS must have an up-to-date signed Health History Form as well as Assumption of Risk, Liability Release, Indemnity Agreement, Picture and Video Waiver and Release to participate in any leadership experience at Summit.

PLEASE READ AND ANSWER THE QUESTIONS BELOW: This form is intended to remind leaders and participants of the seriousness of attempting adventure activities with an old preexisting injury, a heart condition, or other condition which might be aggravated by the event. Please connect with a Summit facilitator if you need to share any additional and pertinent information.
1. Any preexisting injuries (ankle, neck, back, knee, wrist, shoulder, etc.) that might be aggravated by participating? *

Yes No
Explain.
2. Taking any current medications? *

Yes No
Explain.
3. Any heart problems or medication? *

Yes No
Explain.
4. Do you have high blood pressure *

Yes No
Explain.
5. Do you have allergies (bees, insects, medications, etc.)? *

Yes No
Explain.
6. Do you have physical limitations? *

Yes No
Explain.
7. Do you have any special dietary needs? *

Yes No
Explain.
8. What is your current level of activity back at home? *

Low Medium High
9. Are you pregnant or believe you may be pregnant? *

Yes No
Please include any additional information that you feel is relevant.
Attach Resume

Browse Files

Cancel of
Liability Release
Signature *
Parent/Guardian Signature *
Thank you for applying with Five Star Life. Please complete our background check. You will be directed to this page after you submit your application.

** If you have already submitted a background check with Five Star Life, there is no need to fill out the next page. Thank you.
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Education

Previous Employment

Personal History

Health History

Liability Release