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Name *
Date of Birth *
Date of Birth
Home Phone
Home Phone
Cell Phone *
Cell Phone
Permanent Street Address *
Permanent Street Address
Are you authorized to work in the U.S.? *
In case of emergency phone number
In case of emergency phone number
Date Available
Date Available
If your school year ends after Memorial Day, are you available to work?
If you are a student, do yopu play a fall sport?
Can you work through Labor Day?
For your regular pool assignment, how far are you willing to drive? Up to:
How do you plan to get to work?
Have you ever been dismissed from employment for any reason other than lack of work?
Do you now, or have you ever, had a lifeguard certification?
What was/is the expiration date of License or Certificate?
What was/is the expiration date of License or Certificate?
Do you now, or have you ever, had a Pool Operator's certification?
Do we have permission to contact your employer?
I understand that due to my occupational exposure to blood and/or other potentially infectious materials, I may be at risk of acquiring the Hepatitis B virus (HBV) infection. I understand that upon exposure, I am to contact the office immediately and a confidential medical evaluation and follow- up will then be made available. Included in this medical evaluation will be the opportunity to receive the Hepatitis B Immune Globulin (HBIG) vaccination at no charge to me. Please check box and insert your name next to ONE of the following:
I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts shall be cause for dismissal if employed. My typed name below shall have the same force and effect as my written signature when submitted electronically.
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