PYD Application

Full Legal Name*

First NameMiddle NameLast Name

I am interested in this position (check all that apply)*

Choose one*

I am interested in a Full-Time PositionI am interested in a Part-Time Position

Last four digits of your Social Security Number*

Please also upload a current photo of yourself (headshot).

Upload a File

Gender

MaleFemale

Current Age*

Marital Status*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

How long have you lived in [state]? Years and months*

If you have lived in [state] for less than five years, list your complete addresses for the last five years:

E-mail*

Confirmation Email

Phone Number: Best one to contact you*

Area CodePhone Number

Occupation*

Name of Employer*

Number of Years At current employer*

Emergency Contact*

Relationship *

Phone (Emergency Contact)*

T-Shirt Size

Have you received certification in any of the following?

Do you have previous background or training in working with children who have been abused or neglected?

YesNo

If yes, in what way?

Please describe why you wish to be a part of ME INC and work with children and families.

Do you have any medical conditions or concerns, or are you taking any medications that you believe could prevent you from being an effective volunteer that we need to know about in order to help you be effective at camp?

NoYes

Please describe:

High School Name*

Date of Graduation*

College

College Major

Date of Graduation

Other Education

Reference #1 - Name*

First NameLast Name

Reference #1 - Phone*

Area CodePhone Number

Reference #1 - Email*

Confirmation Email

Reference #2 - Name*

First NameLast Name

Reference #2 - Phone*

Area CodePhone Number

Reference #2 - Email*

Confirmation Email

Reference #3 - Name*

First NameLast Name

Reference #3 - Phone*

Area CodePhone Number

Reference #3 - Email*

Confirmation Email

Do you feel you could lead an 1-class with your students with materials we provide?

NoYes

List five (5) strengths you have in working with children: Please be specific*

List five (5) weaknesses you have in working with children: Please be specific*

Following Rules: How well do you follow rules and respond to authority

	1	2	3	4	5

1 is Very Well, 5 is Poorly

I would prefer my to work:

Nashville, TNCleveland, OH

1) Have you ever been convicted of or pleaded guilty to any crimes (including crimes of record which have been expunged and pleas of 'no contest'), including municipal, state and federal?*

NoYes

2) Have you ever been placed on probation, received a Suspended Execution, Suspended Sentence or Suspended Imposition of Sentence for any offense involving a minor child (a child under 18), or been placed on ANY local, state, or federal sexual registry?*

NoYes

3) Have you ever been sued in a civil court of law where the allegations in the suit involved illegal, inappropriate, or sexual conduct or contact with a minor child?*

NoYes

4) Have you ever been subject to any court order involving any sexual, physical or verbal abuse including but not limited to any domestic violence or civil harassment injunction or protective order?*

NoYes

5) Have you ever resigned, been terminated or been asked to resign from a position, whether paid or as a volunteer, due to a complaint(s) of sexual, physical or verbal abuse of minors?*

NoYes

If yes to any above, please explain:*

REPRESENTATIONS AND RELEASE
I understand that for ME INC to carry on a services, it has had to agree to abide by certain policies and parameters established by ME INC, including strict policies against any form of child abuse, and that violation of these policies may be cause for dismissal. Child abuse is punishable by law, and tME INC is bound by law to report allegations of abuse or any inappropriate sexual contact to the proper authorities. ALL reporting is kept confidential, by law. All volunteers must commit to immediately report any behavior that seems suspicious, questionable, abusive or inappropriate between: child-to-child, staff-to-child, and staff-to-staff.

I understand that I will be required to submit to a background check as a condition of acceptance as an employess and that unsatisfactory results, refusal to cooperate, or any attempt to affect the results of these background checks will result in me being removed as a employee or applicant.

I hereby certify that all of the information provided by me in this Application (or in any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in these documents may (or will) be cause for the denial of acceptance as a volunteer, or immediate removal as a volunteer, regardless of the timing or circumstances of discovery.

In consideration of the receipt and evaluation of this Application by ME INC, I hereby authorize you to contact any references, schools attended, former and present employers, charities, courts, and any other person, agency, or organization that may have information about me, and for them to provide to you such information (including opinions) that they may have regarding my character and fitness for working with children; I hereby release any such references, churches, youth groups, schools attended, former and present employers, charities, courts, and any other person, agency or organization who may have provided information about me, including record custodians, both collectively and individually, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply with this authorization. I also agree to hold ME INC and any other person to whom the release above applies, harmless from any damages, specifically including attorney fees and court costs, created by or relating to my unwarranted attempt to collect damages for providing information described above or any other unwarranted action by me in connection with this Application. I waive any right that I may have to inspect any information provided about me or by any person or organization identified by me in the Application process.

I have carefully read the above Application and this Acknowledgement and Release and know and understand its contents; I also know the above is legally binding on me. I sign this Application and Release of my own free will.

Print Name*

Signature*

Employment Application

Important Informatiion

MEDICAL CONCERNS

Education

Personal References* (required for first time employees only) No former employers or relatives.

Personal Profile

Criminal Background

Thank you for your interest in being a part of the ME INC Team!