Y.E.S. Application

Y.E.S. (Youth Enabling Seniors) Application
The Role: The Y.E.S. program connects students interested in helping homeowners with seasonal outdoor chores such as grass cutting, shoveling snow, and raking leaves. In doing so, not only will you be gathering references and experiences for university applications and future work opportunities, but you will be paid directly for making a positive impact in the lives of neighbours in your community: Enabling them to live at home with independence and dignity!
Who You Are: You are dedicated and eager to learn and engage with different work environments. You understand the value of building and maintaining client-worker relationships based on integrity and commitment to equitable, quality service. You are passionate about making a positive change in our community, adaptable and flexible, and confident in supporting the older adult community.
Your Rate: $22/hour, one-hour minimum, paid directly to the student and adults alike when the work is completed.

What You Need To Do: Fill out the application, supply two references (one from school, and one from the community, and return the application to us!
Date*

MonthDayYear
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Home Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Are you available to work during the summer break?*

YesNo
Indicate the Amount of Work Wanted (During Summer Break)*

Occasional0-6 Hours Weekly6-19 Hours Weekly20-25 Hours Weekly26-40 Hours Weekly
Available to Work (During the Summer Break):*

MorningsAfternoonsBoth
Are you available to work during the school year?*

YesNo
Indicate the Amount of Work Wanted (During the School Year)*

Occasional0-6 Hours Weekly6-19 Hours Weekly20-25 Hours Weekly26-40 Hours Weekly
Available to Work (During the School Year):*

MorningsAfternoonsBoth
Primary Mode of Transportation*

BusCarWalk/Cycle
Area You Prefer to Work (Check All That Apply):*

CambridgeKitchenerNorth Dumfries
Available for (Check All That Apply):*

Yard MaintenanceSnow Removal
If you are available for Yard Work, what equipment do you have access to? (Check all that apply.)

Grass Cutting Equipment (Lawnmower, rake, etc.)Garden Maintenance Equipment (Trimmers, clippers, shovel, spade, etc.)No Equipment (Will have to use client-provided equipment)
If you are available for Snow Removal, what equipment do you have access to? (Check all that apply.)

Snow Removal Equipment (Shovel)High-Capacity Snow Removal Equipment (Snow blower, plow)No Equipment (Will have to use client-provided equipment)
Are you eligible to work in Canada?*
I am available to begin work:*
State Any Work and/or Volunteer Experience, of Any Kind, You Have:*
Hobbies and interests:*
Current School:*
Current Year of School:*

Grade 09Grade 10Grade 11Grade 125th-year Student
Are You a Smoker?*

YesNo
Are You Comfortable Working in a Smoking Environment?*

YesNo
Are You Comfortable Working Around Pets?*

YesNo
Do you have any allergies, health concerns, or need for physical accommodations?*
Do you speak, understand, and write in English fluently?*

YesNo
Do you speak, understand and write any other languages? If so, please specify.
How did you hear about Community Support Connections?*

Family/Friend/VolunteerSocial MediaVolunteer Action CentreUniversity/CollegeUnited WayPoster/BrochureNewspaper/Radio/TelevisionCommunity Knowledge/Other AgencyReligious OrganizationKijiji PostingNetworking/Volunteer FairCorporate Volunteer
Emergency Contact*

First NameLast Name
Emergency Contact's Phone Number*

Area CodePhone Number
Relationship of Emergency Contact*
Reference #1 (Academic Reference -- Teacher, Instructor, etc.)*
Relationship:*
Reference #1 Phone Number*

Area CodePhone Number
Reference #1 E-mail
Reference #2 (Community Reference -- Coach, Religious Leader, Work Supervisor, Officer, etc.)*
Relationship:*
Reference #2 Phone Number*

Area CodePhone Number
Reference #2 E-mail
Parent/Guardian Name:*

First NameLast Name
Parent/Guardian Phone Number:*

Area CodePhone Number
Parent/Guardian E-mail*
example@example.com
I give permission for the above applicant to participate in the Y.E.S. program offered by Community Support Connections.

I understand that by participating in the program, they are, in essence, self-employed, and will receive referrals for clients from Community Support Connections.

I further acknowledge that Community Support Connections does not assume liability for injury or damages in connection with this self-employment.
Parent/Guardian Signature:*
Enter the message as it's shown*
Should be Empty:

Y.E.S. (Youth Enabling Seniors) Application