CORPENING MEMORIAL YMCA
CIT APPLICATION
SUMMER 2012
INSTRUCTIONS: Please print, except for the signature on the last page of the application. Each question
should be fully and accurately answered. No action can be taken on this application until all information is
completed. Any questions regarding the application should be directed to the director of the department to
which you are applying. All information you give on this application will be held in strict confidence.
GENERAL INFORMATION:
Todays Date: ____________________________
Full Name: ___________________________________________________________________________________________________________________
Street Address: ________________________________________________________________________________________________________________
City: _______________________________________ State: _________________
Home Phone Number: _____________________
Zip Code: ________________
Daytime Phone Number: ______________________
E-mail Address: ________________________________________________________________________
Have you ever volunteered for the YMCA of WNC? __________
If yes, when? _________________
List any relatives or friends working for us: ___________________________________________________________________
Have you ever been punished with ISS or OSS this past school year? _______________
(Note: a Yes response does not necessarily disqualify you from consideration)
If yes, please explain: __________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
EDUCATION & EXTRACURRICULAR ACTIVITIES:
1.
Name of School: _____________________________________________________________________
State: ____________
GPA: ____________________
2.
Team or Organization: ________________________________________________________________
State: ____________
Position: __________________________________________________________________
Acoomplishments:_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
3.
Team or Organization: ________________________________________________________________
State: ____________
Position: __________________________________________________________________
Acoomplishments:_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
4.
Team or Organization: ________________________________________________________________
State: ____________
Position: __________________________________________________________________
Acoomplishments:_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
6.
Additional Accolades:
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________
VOLUNTEER EXPERIENCE: Please list any community service in consecutive order beginning with your
present organization. Please give accurate hours.
1.
Name of Organization: __________________________________________________________________________________________________________
Street Address: __________________________________________________________________________________________________
City: _________________________________ State: ______________ Zip Code: _____________
Telephone: _____________________________________ Supervisor: ________________________________________
Job Title(s): ______________________________________________, ______________________________________________
Describe work performed: ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
Service Hours: ___________________________________________________________________________
Dates of Service:
From: ___________________________ To: _________________________
Reason for leaving: __________________________________________________________________
2.
Name of Organization: __________________________________________________________________________________________________________
Street Address: __________________________________________________________________________________________________
City: _________________________________ State: ______________ Zip Code: _____________
Telephone: _____________________________________ Supervisor: ________________________________________
Job Title(s): ______________________________________________, ______________________________________________
Describe work performed: ___________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
Service Hours: ___________________________________________________________________________
Dates of Service:
From: ___________________________ To: _________________________
Reason for leaving: __________________________________________________________________
PERSONAL REFERENCES: Three are required, with one being a family member.
1.
Name: ______________________________________________________________________________
Telephone: ______________________________
Street Address: __________________________________________________________________
Relationship: ____________________________
City: _________________________________ State: ______________ Zip Code: _____________
2.
Name: ______________________________________________________________________________
Telephone: ______________________________
Street Address: __________________________________________________________________
Relationship: ____________________________
City: _________________________________ State: ______________ Zip Code: _____________
3.
Name: ______________________________________________________________________________
Telephone: ______________________________
Street Address: __________________________________________________________________
Relationship: ____________________________
City: _________________________________ State: ______________ Zip Code: _____________
STATEMENT OF APPLICANT: (Please read before signing)
In the YMCA of Western North Carolinas effort to attract the highest quality staff, I have been advised that as a part of
the application process for selection with the Corpening Memorial YMCA, an extensive inquiry will be made concerning my
prior activities, and character and I fully consent to and authorize all such inquiries. Additionally, I authorize the
Corpening Memorial YMCA to request my school and or volunteer record from any former school or organization. I
further understand that inquiries may be made, concerning me, my background and experience. Inquiries or requests may
be made by you, or your representatives, to any governmental agency, including law enforcement agencies or
departments, or any other party with a legal and proper interest. I hereby waive any right to claim that any request or
investigation is an invasion of my privacy, since they are made with my consent and it is in my interest that I be
considered for selection.
I certify that all statements made by me on this application are true and complete to the best of my knowledge and that I
have withheld nothing that would, if disclosed, affect this application unfavorably. I understand and agree that any
misrepresentation or omission of facts would exclude my being considered for selection or, after selection, would be
cause for termination of program involvement with the Corpening Memorial YMCA.
I understand and agree that if I am selected, there is no contract period for program participation and my program
evolvement would be solely an at will basis giving either me or the Corpening Memorial YMCA the right to terminate my
evolvement at any time with or without notice, with or without cause, without liability or obligation. I further understand
that my status as an at will program participant, if I am selected by the Corpening Memorial YMCA, may not be altered
either by statements, by writings, or conduct.
I hereby acknowledge that I have read and understood the above statements and that I agree to the above and voluntarily
sign this application. I further declare, under penalty of perjury, that the information I have provided in this application is
true and correct.
Signature of Applicant_________________________________________________
Date___________________
