Date of Application

First Name *

Middle Name

Last Name *

Street Address

City

State/Province

ZIP / Postal Code

Email Address *

Phone *

Position(s) Applying For:

Position TypeFlag Football RefereeFall Soccer RefereeAfter School Program Staff

Work Eligibility:

I am at least 18 years of age:YesNo

If you are under 18 years of age, can you provide required proof of your eligibility to work?YesNo

If you are a high school student, what is your current age?15161718

Are you currently employed?YesNo

May we contact your present employer?YesNo

Availability

Times Available to WorkMorningsAfternoonsEveningsWeekends

Date Available for Work

Can you travel from park to park if a job requires it?YesNo

Do you have a valid driver's license?YesNo

Please briefly describe the position(s) you are applying for:

Education

High School Name

Years Completed

Diploma/Degree

College/Other

Course of Study

Years Completed

Diploma/Degree

Certifications

Extracurricular Activities

References:

Name

Relationship

City, State

Phone

Name

Relationship

City, State

Phone

Name

Relationship

City, State

Phone

Work History

Employer Name

Employer Address

Employer Phone

Job Title

Supervisor

Reason for Leaving

Employer Name

Employer Address

Employer Phone

Job Title

Supervisor

Reason for Leaving

Criminal Background Information

"I affirmatively state and certify under penalties of perjury that I have never been convicted of any of the enumerated criminal or drug offenses set forth at 70 ILCS 1205/8-23, nor have I, within seven years prior to the date of this application, been convicted of any felony under the laws of the State of Illinois or any offense committed or attempted to be committed in any other state or against the laws of the United States that if committed or attempted to be committed in this state would be punishable as a felony. I authorize the Effingham Park District as a condition of consideration of my employment application to conduct an investigation of the truth of this statement."I certify that the answers given herein are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for aperiod of time not to exceed 90 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with our without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide in all rules and regulations of the employer

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