CO-OP/Work Study Student Job Application

This facility is an equal opportunity employer and fully subscribes to the principles of Equal Employment Opportunity. It is the policy of this facility to provide employment, compensation, and other benefits related to employment based on qualifications, without regard to race, color, religion, national origin, age, sex, veteran status or disability, or any other basis prohibited by federal or state law. As an equal opportunity employer, this facility intends to comply fully with all federal and state laws, and the information requested on this application will not be used for any purpose prohibited by law. Disabled applicants may request any needed accommodation.

Name:*

First NameLast Name

Date of Birth:*

Personal Email Address:*

By providing your email, you agree to be added to our marketing list to receive updates, promotions, and news; you can unsubscribe at any time.

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Ethnicity:*

High School (now attending):*

Grade/Year in School:*

Dates of Experience:*

Fall (August)Spring (January)Both

Hours per week:*

Areas of Interest: (Select all that apply)

Name:*

First NameLast Name

Relationship:*

Work Phone:

Cell Phone:*

Today's Date:*

I HEREBY CERTIFY that the answers given by me to the above questions and statements are true and correct and hereby voluntarily authorize this facility to contact references, past or present employers, persons, schools, law enforcement agencies, and any other sources of information which may be relevant to my application for employment. Further, I release from all liability or responsibility all persons, companies, or corporations supplying such information. I voluntarily grant this release to support my application for employment at Memorial Hospital, Memorial Medical Clinics & Hancock County Senior and Childcare Services. I agree to inform the facility of any special concerns I may have related to information that may be discovered during this investigation in the space below. I further understand that all information and documents acquired by Memorial Hospital, Memorial Medical Clinics & Hancock County Senior and Childcare Services will be maintained as confidential by the facility and that the facility will not release such information to me. It is understood and agreed that any misrepresentation, false statement, or omissions by me in this application will be sufficient reason for rejection of my application or for dismissal at any time during my employment, without liability to this facility.

I further understand that my employment is at will and that either party is free to terminate the employment relationship at any time without cause. I also understand that no representative of the facility has the authority to enter into any agreement for employment for any specified period of time and that this facility is not guaranteeing employment for anyone. No employment contract is created by virtue of my being hired by this facility. I have read, understand, and agree with the above statement.

If employed, I agree to abide by all of the work and safety rules of the facility. If employed, I will be required to complete an Employment Verification Form (I-9). I agree to any and all pre-placement assessment(s) as may be deemed necessary by Memorial Hospital, Memorial Medical Clinics & Hancock County Senior and Childcare Services, and further, understand that my employment is contingent upon my completion of the facility pre-placement assessment. I understand that this facility is committed to maintaining a drug-free workplace. I am aware that the facility may require a drug test as part of the hiring process. Also, if employed, I realize that the facility may conduct post-accident and reasonable suspicion drug and/or alcohol testing of its employees. I have read, understand, and agree with the above statement.

By signing below you acknowledge that you have read, understand, and agree with the above statement.

Student Signature:*

Parent or Guardian Signature (Student under 18 years of age)*

CO-OP/Work Study Student Job Application

Emergency Contact: (Parent or Guardian)

EMPLOYMENT UNDERSTANDING