SEASONAL ...

Boys & Girls Club of Ouachita County TEMPORARY/SEASONAL EMPLOYEE APPLICATION NAME: FIRST DATE OF BIRTH:

MIDDLE /

/

AGE:

ADDRESS:

YEARS EMPLOYED:

SSN#:

CITY:

EMAIL ADDRESS: CURRENT OR MOST PREVIOUS EMPLOYER:

LAST HOME PHONE #: ST:

ZIP:

CELL PHONE #:

TITLE/DUTIES:

SUPERVISOR’S NAME:

SUPERVISOR’S PHONE #:

YOUTH SERVICE BACKGROUND/EXPERIENCE: POSITION REQUESTED:

REFERENCES:

UMPIRE/REFEREE CONCESSION STAND GATE/DOOR SCOREKEEPER OTHER: NAME

SEASON/SPORT:

PHONE #

SPRING/SUMMER FALL WINTER BASEBALL SOFTBALL T-BALL SOCCER BASKETBALL

HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENSE?

YES

NO

HAVE YOU EVER BEEN CHARGED WITH CHILD ABUSE OR NEGLECT?

YES

NO

HAVE YOU EVER HAD YOUR DRIVER’S LICENSE SUSPENDED?

YES

NO

HAVE YOU EVER USED ILLEGAL DRUGS?

YES

NO

DO YOU HAVE ANY MEDICAL CONDITION WE SHOULD BE AWARE OF?

YES

NO

IF YES, PLEASE EXPLAIN:

I, the undersigned, certify that the above information is true and may be verified by a background check at the Boys & Girls Club of Ouachita County’s discretion.

Signature

Date