Mayor Antonio R.

Villaraigosa Summer Night Lights

SITE: GLASSELL PARK

Gang Reduction and Youth Development Youth Squad Employment Application

Applicant Information
First

Full Name: Address:

Last Street Address City

M.I.

DOB:

Apartment/Unit # State ZIP Code

Phone:

) Social Security No.:

E-mail Address: Salary: SNL Site:

YES YES NO NO

Date Available: Position Applied for: Youth Squad

$3,500 Gross*

Have you ever worked for this company? Have you ever been convicted of a felony? If yes, explain:

If so, when?

Education
High School: From: College: From: Other: From: To: To: To: Address: Did you graduate? Address: Did you graduate? Address: Did you graduate?
YES NO YES NO YES NO

Degree:

Degree:

Degree:

Please list three references.

Full Name: Company: Address: Full Name: Company: Address: Full Name: Company: Address:

References
Relationship: Phone: ( )

Relationship: Phone: ( )

Relationship: Phone: ( )

*Gross- Your salary before tax has been taken from it.

Last: ____________________, First: _________________

GLASSELL PARK Site :_____________________

Previous Employment
Company: Address: Job Title: Responsibilities: From: To: Reason for Leaving:
YES NO

Phone:

Supervisor: Starting Salary: $ Ending Salary: $

May we contact your previous supervisor for a reference? Company: Address: Job Title: Responsibilities: From: To:

Phone:

Supervisor: Starting Salary: $ Ending Salary: $

Reason for Leaving:

YES NO

May we contact your previous supervisor for a reference? Company: Address: Job Title: Responsibilities: From: To:

Phone:

Supervisor: Starting Salary: $ Ending Salary: $

Reason for Leaving:

YES NO

May we contact your previous supervisor for a reference?

Military Service
Branch: Rank at Discharge: If other than honorable, explain: From: Type of Discharge: To:

Availability
Are you available to work the following hours during the July 5th September 1st? (See Below) Please mark an X over the date that you will not be free: MONDAY TUESDAY 1pm-5pm WEDNESDAY 3:30pm12:00am THURSDAY 3:30pm12:00am FRIDAY 3:30pm12:00am NO: SATURDAY 3:30pm12:00am SUNDAY
YES NO

Are you available starting June 25th- June 30th from 9-5pm? YES :

If NO, which dates: _______________

Last: ____________________, First: _________________

GLASSELL PARK Site: _____________________

Additional Information
Do you have reliable transportation to and from work?
YES NO

Please explain:
YES NO

If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States? Are you able to perform the essential functions of the job for which you are applying? If NO, please explain:

YES

NO

How did you hear about this job opportunity? _______________________________________________________________ Have you worked at the park before? _____________________________________________________________________ Please list any languages spoken other than English:

Uniform T-Shirt Size:

XL

2XL

3XL
Ethnicity: Hispanic or Latino Not Hispanic or Latino

4XL
Gender: Male Female

Race: American Indian or Alaska Native Asian Black or African American Current Grade Level: 8th 11th 9th 12th 10th High School Graduate Employment History: Previously Employed Never Been Employed

Native Hawaiian or Other Pacific Islander White Other ______________________________ School Track: A D B Traditional C

EDUCATION AND EMPLOYMENT HISTORY: Independent Studies: Yes No School Attending

Employment Status: New applicant Re-hire

If you are a rehire, when did you first apply to Summer Night Lights? Month/Day/Year_____/______/___________

PARENT/GUARDIAN AND EMERGENCY CONTACT INFORMATION: Parent or Guardian (Name and Relationship): Parent/Guardian Home Phone: Parent/Guardian Work Phone:

In Case of Emergency, please contact (Name and Relationship):

Emergency Contact Home Phone:

Emergency Contact Work Ph.:

DEMOGRAPHIC INFORMATION: Are you legally entitled to work in the United States? Yes No (Applicants are required to furnish proof of identity and legal work authorization prior to hire) Selective Service Pregnant or Parenting Disabled: Probation: Youth: Registrant Yes No Yes No Yes No (Military): Yes No Receiving School Family TANF (Temporary Foster Youth: Family Receiving Food Stamps: Lunch: Aid for Needy Families): Yes No Yes No Yes No Yes No Family SSI (Supplemental Security Income): Yes No Family RCA (Refugee Cash Assistance): Yes No Family Composition: Single Parent Two-Parent Family

Homeless: Yes No Family GA (General Assistance): Yes No

Adult, no children

Last: ____________________, First: _________________

GLASSELL PARK Site: ______________________

I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the statements checked by the Mayors Office of Gang Reduction and Youth Development Summer Night Lights program. I understand that completion of this application does not guarantee my selection into the Summer Night Lights Program. Signature of Applicant ______________________________________________ Date ______________ PARENTAL PERMISSION & MEDICAL CONSENT (REQUIRED FOR ALL APPLICANTS BETWEEN 14 & 17 YEARS OLD) MEDICAL INFORMATION: Does your child have allergies or any medical conditions that may limit or restrict their work activities, or which should be known about in an emergency? No Yes (If marked yes, please describe condition *) Date of last Tetanus shot: ________________________________ I hereby grant the Mayors Office of Gang Reduction and Youth Development Summer Night Lights program permission to use my childs likeness in photograph(s)/video in any and all kinds of its publications, promotional materials or on the Internet, without any further authorization, now or in the future, in perpetuity. I will make no monetary or other claim against the Mayors Office of Gang Reduction and Youth Development Summer Night Lights program for the use of the photograph(s)/video. Please select one: YES NO Signature of Parent or Guardian:_______________________________ Witness:______________________________ Date:________________ I have read the Mayors Office of Gang Reduction and Youth Development Summer Night Lights program information and understand that it includes outdoor work requiring physical labor. I hereby grant permission for my son or daughter to participate in all program activities, including transportation to sites in the Greater Los Angeles area. I hereby authorize and request that emergency medical treatment be performed as required. Signature of Parent or Guardian _________________ ____________________________ Date______________
* The Mayors Office of Gang Reduction and Youth Development Summer Night Lights program is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex age, national origin, disability, veteran status, or any other classification protected by Federal, state or local law. The information in this box will be used only in the compilation of data for Equal Employment Opportunity reporting. Completion of this data is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired.

Disclaimer and Signature I certify that my answers are true and complete to the best of my knowledge. I understand that this position requires that I be between 17 to 22 years of age to be considered. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I understand that submission of this application does not guarantee employment or an interview. After potential interview, I understand that part of the application process will require fingerprinting clearance and possible drug and/or alcohol testing.
Signature: Date: