2022 Application Employment Application PERSONAL INFORMATION Name (First & Last) * Date of Birth * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Home Phone Mobile Email * POSITION/AVAILABILITY (include resume if applying as instructor) Position you are applying for: * Instructor Counselor Jr. Counselor Resume * Drop a file here or click to upload Choose File Maximum upload size: 33.55MB Check the weeks you are available. (Instructors MUST be available for all 5 weeks. Counselors and Jr. Counselors must be available for 2 weeks minimum; 3 weeks required to be eligible for a scholarship.) Week of July 5 - 8, 2022 AM PM Week of July 11 - 15, 2022 AM PM Week of July 18 - 22, 2022 AM PM Week of July 25 - 29, 2022 AM PM Week of August 1 - 5, 2022 AM PM # of Years Sailed Last level of sailing completed Are you planning to enroll in any classes during the summer? Yes No (NYSS encourages employees to participate in classes when possible.) Skills and Qualifications Check all of these that apply. Include date of certification & certification number, if applicable, & date of expiration. US Sailing Level 1 Certification No Yes US Sailing Level 1 Certification Information US Sailing Level 2 Certification No Yes US Sailing Level 2 Certification Information First Aid / CPR certified No Yes First Aid / CPR certified Information State Safe Boating Certificate No Yes State Safe Boating Certificate Information US Sailing Counselor Certification No Yes US Sailing Counselor Certification Information LEGAL HISTORY Have you ever been convicted of a crime? No Yes Explain EMERGENCY CONTACT INFO Name * Phone * MEDICAL HISTORY Do you have any medical conditions which would affect your ability to perform your duties? No Yes Explain I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above. Date Applicant Signature Clear Parent’s Signature (if applicant is under 18) Clear reCAPTCHA Email File Upload Drop a file here or click to upload Choose File Maximum upload size: 33.55MB Text Star Rating 1 Star 2 Stars 3 Stars 4 Stars 5 Stars Time 121234567891011 : 0030 AMPM Section Section Submit
