CHARIS YOUTH CENTER
714 W. Main St · Grass Valley, CA 95945
(530) 477-9800 · Fax (530) 477-9803
Employment Application

Personal Information  
Last Name
 
First Name
 
Middle Name
 
Street Address
 
City
 
State
 
Zip Code
 
Phone
 
Other names you have had
 
     
Position Desired
   
Job Title
 
Desired Salary
 
Date Available
 
Type of Employment
  Full-Time
On Call		 Part-Time
Internship
Have you ever applied before?
  Yes No
If yes, give date
 
What prompted your
application to our company?
  Advertisment
Agency
 Referral
Other
 
   
Personal History
   
Date of First Aid Card
 
Date of Last Physical Exam
 
Date of Last TB
 
     
Education and Training    
     
High School
   
Did you graduate from High School?
  Yes No
If no, did you receive a GED or equivalent?
  Yes No
     
College / University
   
 
Name
 
 
Location
 
Diploma, degree or certificate obtained?
  Yes No
 
List degree(s) received
 
If a degree was not obtained, list the number of credits completed
 
     
List other job-related training, scholastic honors, professional licenses, certifications or credentials. Official documentation may be required if hired.  
     
Experience    
     
Most Recent Employer
   
 
Company
 
 
Company (cont.)
 
 
Address
 
 
Address (cont.)
 
 
Supervisor's Name
 
 
Phone Number
 
 
May we Contact?
  Yes No
 
Your Job Title
 
 
Date Employed From
 
 
Date Employed To
 
 
Reason for Leaving
 
     
Previous Employer
   
 
Company
 
 
Company (cont.)
 
 
Address
 
 
Address (cont.)
 
 
Supervisor's Name
 
 
Phone Number
 
 
May we Contact?
  Yes No
 
Your Job Title
 
 
Date Employed From
 
 
Date Employed To
 
 
Reason for Leaving
 
     
Previous Employer
   
 
Company
 
 
Company (cont.)
 
 
Address
 
 
Address (cont.)
 
 
Supervisor's Name
 
 
Phone Number
 
 
May we Contact?
  Yes No
 
Your Job Title
 
 
Date Employed From
 
 
Date Employed To
 
 
Reason for Leaving
 
     
References    
     
Reference 1
   
Name
 
Phone Number
 
Relationship
 
     
Reference 2
   
Name
 
Phone Number
 
Relationship
 
     
Reference 3
   
Name
 
Phone Number
 
Relationship
 
     
Other    
Do you meet the minimum age requirement of 21 years of age?   Yes No
Can you submit verification of your identity and legal right to work in the United States?   Yes No
It is a requirement for employment in a Community Care Licensing Facility that fingerprinting is conducted and reviewed for employment approval by the California Department of Social Services, Community Care Licensing Divisions' Caregiver Background Check Bureau (CBCB).
I have read the statement on fingerprint requirements to work at Charis youth center.		   Yes No
     
Do you meet the requirements to have a current, valid California driver's license?   Yes No
     
I understand that as part of the condition for employment that my driving record will be reviewed and must meet the agency's insurance company's requirements to be a covered driver.   Yes No
     
Employee Availability    
  Employees hired to work in the School, Rehabilitative Enrichment Program, or Residential Program may be scheduled to work within the following time frames:
Teacher Counselors
School Days 2:00 pm - 10:00 pm
Non-School Days 7:30 am - 10:00 pm
Weekends 7:30 am - 3:00 pm
3:00 pm - 10:00 pm
or double shifts
Teaching Assistants
School Days 6:30 am - 3:00 pm
Non-School Days 7:30 am - 3:30 pm
Weekends NA
 
 
Late Night Child Care Workers
10:00 pm - 7:30 am

I understand that availability to work assigned schedules is an
important consideration for Charis Youth Center during the
hiring process and therefore, I now state that, if hired, I am
available to work as follows:
     
    From To
Monday  
Tuesday  
Wednesday  
Thursday  
Friday  
Saturday  
Sunday  
     
I certify that all statements are true, and I give permission for
necessary verification.