Scroll to see more shifts & complete your submission at the bottom of the page.Click here to scroll down.
Required fields are marked with an asterisk (*). One of the fields below is a file upload/attachment, the file size must be less than 10MB.What is your first name? *
What is your middle name? *
What is your last name? *
What pronouns do you use?
What is your phone number?
What is your street address? *
What city do you live in? *
What state do you live in? *
What is your zipcode?
What county do you live in? *
Employer/Occupation: *
Any special talents or skills you have that you feel would benefit our organization?
What jobs are you interested in doing? *
Please indicate days available: *
Please indicate times you are available. *
Any physical limitations?
What is your shirt size? *
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.
WAMY COMMUNITY ACTION, INC has put in place preventative measures to reduce the spread of COVID-19; however, WAMY cannot guarantee that you will not become infected with COVID-19. Further, returning to in-person work could increase your risk of contracting COVID-19.
By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by returning to in person work office and having contact with clients and exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 during work hours may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, volunteers, and program participants and their families.
I voluntarily agree to assume all the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance in the office or exposure to any other staff or clients (“Claims”). On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless WAMY, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs, leave or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the WAMY, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any WAMY.
WAMY strongly encourages all employees to get vaccinated, especially if you work with clients, and other staff closely.
In the event of a medical emergency, are there any emergency procedures or restrictions on medications of which emergency personnel should be aware of? If yes, please explain (seizures, diabetic, high blood pressure, etc.)
Full Name of Primary Contact in case of emergency: *
Primary Emergency Contact Relationship: *
Primary Emergency Contact Phone Number: *
Primary Emergency Contact Alternate Phone Number:
Primary Emergency Contact Email Address:
Full Name of Secondary Contact in case of emergency: *
Secondary Emergency Contact Relationship: *
Secondary Emergency Contact Phone Number *
Secondary Emergency Contact Alternate Phone Number?
Secondary Contact Email Address:
WAMY Community Action, Inc., ("the company) may obtain a “consumer report” about you from a consumer reporting agency for employment purposes. A “consumer” report is a background screening report that may contain information regarding your criminal history, driving history, and other information about you. It may bear upon your character, general reputation, personal characteristics, and/or mode of living.
NOTICE REGARDING BACKGROUND INVESTIGATION
PURSUANT TO CALIFORNIA LAW
WAMY Community Action, Inc., (“the Company”) intends to obtain information about you from an investigative consumer reporting agency for employment purposes. Thus, you can expect to be the subject of "investigative consumer reports" obtained for employment purposes. Such reports may include information about your character, general reputation, personal characteristics, and mode of living. With respect to any investigative consumer report from an investigative consumer reporting agency ("ICRA"), the Company may investigate the information contained in your employment application and other background information about you, including but not limited to, your criminal history, driving records, or other information about you. These reports may be used as a factor in making employment decisions. The source of any investigative consumer report (as that term is defined under California law) will be SentryLink LLC, 7500 Greenway Center Drive, Suite 1040, Greenbelt, MD 20770, (877) 736-8791. Information regarding SentryLink’s privacy practices (including information about whether any consumer personal information will be sent outside the U.S. or its territories) may be found at www.sentrylink.com
Under California Civil Code section 1786.22, you are entitled to find out from an ICRA what is in the ICRA’s file on you with proper identification, as follows:
In person, by visual inspection of your file during normal business hours and upon reasonable notice. You also may request a copy of the information in person. The ICRA may not charge you more than the actual copying costs for providing you with a copy of your file.
A summary of all information contained in the ICRA’s file on you which is required to be provided by the California Civil Code and will be provided to you via telephone, if you have made a written request with proper identification for telephone disclosure and the toll charge, if any, for the telephone call is prepaid by or charged directly to you.
By requesting a copy be sent to a specified addressee by certified mail. ICRAs complying with requests for certified mailings shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the ICRAs.
"Proper Identification" includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. Only if you cannot identify yourself with such information may the ICRA require additional information concerning your employment and personal or family history in order to verify your identity.
The ICRA will provide trained personnel to explain any information furnished to you and will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection.
You may be accompanied by one other person of your choosing, who must furnish reasonable identification. An ICRA may require you to furnish a written statement granting permission to the ICRA to discuss your file in such person’s presence.
Please check here if you would like to receive a copy of an investigative consumer report (as defined by relevant state law) at no charge if one is obtained by the Company. _____
AUTHORIZATION REGARDING BACKGROUND INVESTIGATION
By signing below, I acknowledge receipt of the following separate documents (and certify that I have read and understood them):
DISCLOSURE REGARDING BACKGROUND INVESTIGATION; A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT; and ADDITIONAL STATE LAW NOTICES.
By signing below, I also authorize W.A.M.Y. Community Action, Inc. to obtain “consumer reports” (deemed “investigative consumer reports” under California law) about me at any time during the hiring process and throughout my employment, if applicable.
Please supply the following information to facilitate a background check.
Other Names (s) Maiden/Married *
What is your birthday? *
A valid date as MM/DD/YYYY (for example: 11/30/2015)
What is your Social Security Number *
What is your Driver's License Number and State Issued? *
Please list your last (5) five residences starting with your current and time at residence? *
I have read the WAMY Community Action, Inc. ("WAMY") Conflict of Interest Policy set forth and agree to comply fully with its terms and conditions at all times during my service as a member of the WAMY Board of Directors, an officer, volunteer, or a key employee of WAMY. If I become aware of any actual or potential conflicts of interest at any time following the submission of this form, or if the information provided below becomes inaccurate or incomplete, I will promptly notify the WAMY Board of Directors or the Chief Executive Officer of WAMY in writing.
Disclosure of actual or potential conflicts of interest:
Do you receive compensation as Officer, Director, committee member, task force member, or key employee of WAMY? *
Other than reimbursement of reasonable expenses, have you received or do you expect to receive more than $10,000 per year from WAMY for services provided as an independent contractor? *
Have you received or do you expect to receive any material financial benefit from WAMY in addition or part from the benefits described in the above inquires? *
Does any family member receive compensation or material financial benefit from WAMY? *
Do you have a family relationship or business relationship with any current or former Officer, Director, or key employee of WAMY? *
If you answered "Yes" to any above, please explain in a statement below.
I understand that I will be volunteering at my own risk and the organization, its employees, and affiliates cannot assume any responsibility for any liability for any accident, injury, or health problem which may arise from any volunteer work I perform for the organization. I agree that all the work I do is on a volunteer basis, and I am not eligible to receive any monetary payment or reward. I also agree to a complete background check upon assignment.
