Youth Life Center Job Application 
Thank you for your interest in joining our team!
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Email *
Today's  Date: *
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Name *
First and last name
Email *
Phone number *
Birthdate:
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Last 4 of your Social Security Number *
Emergency Contact *
First and last name
Which position are you interested in? *
Available start date? *
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Are not a US citizen?
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Has bond, background check or security clearance ever been denied and/or canceled?
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Highest level of education? *

PLEASE LIST EMPLOYMENT HISTORY FOR THE PAST TEN YEARS, BEGINNING WITH YOUR MOST CURRENT OR LAST EMPLOYER. If you have been unemployed during any time within the past ten years, list how you spent your time, e.g. student, housewife, unemployed, etc.  If you need addition space please use separate employment record form. 

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Have you ever been shown by credible evidence, e.g., a court order or jury, a department’s investigation or other reliable evidence to have abused, neglected or deprived a child or adult or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct?
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Under the American with Disabilities Act of 1991, this program is required to reasonably accommodate individuals with a disability.  The reasonable accommodation requirement applies to the application process, any pre-employment testing, interviews and actual employment, but only if the program supervisor is made aware that an accommodation is required.  If you are disabled and require accommodation, you may request it at any time during the interview process. You are obligated to inform the program director of your needs if it will impact your ability to perform the job for which you are applying.
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Having read the job description for the position for which you are applying, are you in all respects, able to adequately perform the duties as described?                     
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Do you have a valid driver’s license? If yes, give license number and class of license.
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Have you had First Aid and CPR training within the past two years?   If yes, give expiration date:         


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Bright From the Start: Georgia Department of Early Care Learning requires annual child care training, are you willing to participate? 

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I certify that all information on this application is correct.  I have not given any false statement concerning my qualification requirements. 

Your name serves as an electronic signature:  *
Enter your first and last name
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