Chemung County Youth Bureau Employment Application

Chemung County Youth Bureau Employment Application

599 Harris Hill Road, Elmira, NY 14903, 607-737-2907
Program & Position Applied For *
You must be at least 17 years of age by July 1st to be elgible to apply for Summer Cohesion
You must be at least 18 years of age to be elgible to apply for Spot
You must be at least 15 years of age to be elgible to apply for Super Saturday
You must be at least 21 years of age to be elgible to apply for JAWS
Name *

First Name Middle Inital Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Type of Phone *

Cell Land Line
Phone Number *
Type of Phone

Cell Land Line
Phone Number
Social Security Number *
Email *
example@example.com
Are you under 18 years of age *

Yes No
If yes, enter your Birth Date

Month Day Year

Provide the school district, city/town/village, county and state of which you are an actual permanent legal resident and indicate how long you have been residing continually, up to and including the date of this application. (You must enter a value in EACH cell) *

Name

Years

Months

School District

City/Town/Village

County

State

Were you ever dismissed or discharged from any employment for reasons other than lack of work or funds? *

Yes No
Did you ever resign from any employment rather than face dismissal? *

Yes No
Did you ever receive a discharge from the Armed Forces of the United States which was other than “Honorable” or which was issued under other than honorable circumstances? *

Yes No
Have you ever been convicted of a crime (felony or misdemeanor)? *

Yes No
Have you ever forfeited bail bond posted to guarantee your appearance in court to answer to any criminal charges? *

Yes No
Are you now indicted for any crime (felony or misdemeanor)? *

Yes No
Education and Certifications

List your current certifications

First Aid

CPR

Other

Type

Date Issued

Work Experience
Do you have work experience? *

Yes No
Please list the two most recent positions.
Name - Reference 1

First Name Last Name
Address - Reference 1

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number - Reference 1
Start Date of Employment - Reference 1
MM-DD-YYYY
End Date of Employment - Reference 1
MM-DD-YYYY
Position - Reference 1
Name - Reference 2

First Name Last Name
Address - Reference 2

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number - Reference 2
Start Date of Employment - Reference 2
MM-DD-YYYY
End Date of Employment - Reference 2
MM-DD-YYYY
Position - Reference 2
Have you worked for Chemung County Youth Bureau before? *

Yes No
If yes, what program(s), when, and location(s)?
Indicate all experiences you have working with youth

Teacher Sports Drama Arts & Crafts Nature/Outdoors Music Babysitting
What age group(s) do you prefer to work with?

4-5 years 6-7 years 8-9 years 10-12 years 13-15 years 16-18 years
1st Letter of Recommendation

Browse Files
Upload Letter Here Cancel of
2nd Letter of Recommendation

Browse Files
Upload Letter Here Cancel of
- Chemung County Youth Bureau is an Equal Opportunity Employer -

– Applications will be kept on file for one (1) calendar year –
– Incomplete Applications will not be processed –
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Chemung County Youth Bureau Employment Application

Education and Certifications

Work Experience