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Application for Employment City Website: http://www.cityofcody-wy.gov Email:[EMAIL REDACTED] 1338 Rumsey Ave. PO Box 2200 CODY, WY 82414 (307) 527-7511 An Equal Opportunity Employer AQUATIC SEASONAL 2019 Cff'I· OP" Qx:,y WYO r:N C POSITION APPLIED FOR DATE OF APPLICATION__ _ _ LAST FIRST MIDDLE LIST OTHER NAMES USED, IF ANY _ MAILING ADDRESS STREET OR PO BOX CITY STATE ZIP CODE PRIMARY TELEPHONE NUMBER ( ) - AL TERNA TE TELEPHONE NUMBER ) _ EMAIL ADDRESS _ Are you under the age of 14? YES D NO D Are you over the age of 18? YES D NOD (For Police Officers in WY, the minimum age is 21) Have you ever been employed by the City of Cody? YES D NO Dlf yes, give 1 understand, if hired, I will be required to provide proof of eligibility to work in the United States. YES D NO D Have you ever been convicted of any law violation other than a minor traffic violation? YES D NO D ("YES" answer does not automatically disqualify you from employment since the nature of the offense, date and the Job for which you are applying will also be considered.) If yes, give details: Are you related to anyone presently working for the City of Cody? YES D NO Df Yes, list Do you have a valid license? YES D NO D Driver's License# STATE? Do you have a Commercial Driver's License? YES D NO D (A,B,C) Endorsements Held: Hazardous Material D Tanker D Airbrakes D Passenger D Have you ever been terminated, dismissed or asked to resign from any positiooYES D NO If yes, please explain . Educational Background COLLEGE/UNIVERSITY/TRADE SCHOOLS CITY/STATE High School: CREDITS COMPLETED DEGREE/ DIPLOMA YEAR MAJOR MINOR ---PAGE BREAK--- ---PAGE BREAK--- CERTIFICATION OF ACCURACY & AUTHORIZATION TO RELEASE INFORMATION I certify that all information provided in this application is true and complete. I understand misrepresentation or omission of facts during the application or selection process may disqualify me from further consideration and may be cause for dismissal. I understand the City of Cody may conduct a background investigation, which may include obtaining information as to my character, reputation, and mode of living. This may include interviews with my relatives, neighbors, friends, former employers, schools and others. I authorize the City of Cody to investigate my employment background and personal history. I authorize the City of Cody to obtain any and all information relevant to determining my qualifications for the job for which I have applied. I further authorize the City of Cody to obtain copies of and review any and all employment records, documents and such other information as the City of Cody may determine relevant to its investigation. I agree to sign an authorization and consent to release of information to allow the City of Cody to obtain copies of prior employment records, documents and information from prior employers, organizations, references, and individuals who may have information relevant to my qualifications to work for the City of Cody. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I understand that I may also be required to successfully pass drug and alcohol screening examinations. I hereby consent to pre- and/or post-employment drug and alcohol screens as a condition of employment, if required. I have read, understand, and by my signature, consent to these statements. I authorize investigation of all information contained in this application. Signature of Applicant Date ALL APPLICANTS OVER AGE 18 must complete the Application for Child & Adult Abuse/Neglect Central Registry Screen Document (pages 5/6 of application and return with application) ---PAGE BREAK--- Aquatics Division Job Title Rate of Pay Aquatics I $9.54 Aquatics II $10.27 Aquatics III $11.34 Aquatics IV $15.46 Aquatics I: Duties include serving as an aide during swimming lessons, dispatching patrons down the water slide, interacting with the public and assisting with custodial duties. Employee must be willing to communicate clearly and concisely with the public of all ages. Employees must be at least 14 year of age and available to work approximately 10-40 hours per week depending upon the season including evenings, weekends, and holidays. May assist other City divisions as assigned. Aquatics II: Employees must be certified through the American Red Cross as either a Lifeguard or Water Safety Instructor and be certified in CPR (preferably Professional Rescuer). Water Safety Instructor’s must be at least 16 years of age and duties include planning, instructing and evaluating the American Red Cross Learn to Swim program. Employee must be able to assess swimming skills for various levels and determine appropriate instruction. Lifeguards must be at least 15 years of age and duties include patron safety, recognizing unsafe conditions, implementation of safety protocol, and emergency response. Employees will assist with custodial duties and water testing and maintenance. Employees must be able to communicate clearly and concisely with patrons of all ages. Employees are expected to demonstrate a high level of professionalism, maturity and responsibility. Participation in training and frequent skills review is mandatory. Employees should expect to work approximately 10-40 hours per week depending on the season including evenings, weekends and holidays. May assist other City divisions as assigned. Aquatics III: Employees must be certified through the American Red Cross as both a Lifeguard and a Water Safety Instructor and serve in both capacities on a regular basis. Duties of the Aquatics II apply to the Aquatics III position. Employees should expect to work approximately 10-40 hours per week depending on the season including evenings, weekends and holidays. Duties will be assigned based on qualifications and department needs. May assist other City divisions as assigned. Must be at least 16 years of age. Aquatics IV: Employees must be certified through the American Red Cross as Lifeguard or a WSI and serve in this capacity on a regular basis. Duties of the Aquatics II apply to the Aquatics IV position. Employees should expect to work approximately 10-40 hours per week depending on the season including evenings, weekends and holidays. Will perform as “shift supervisor” and be responsible for assigned staff during shift, implementation of shift duties/responsibilities, review daily and weekly maintenance logs. Review timesheets at the end of each day. Assist in performing duties associated with closure of pool area. Some light chemical usage/monitoring required. Duties will be assigned based on qualifications and department needs. May assist other City divisions as assigned. Must be at least 18 years of age in most positions. ---PAGE BREAK--- SS-26 INV 7/1/2018 Page 1 of 2 APPLICATION FOR CHILD & ADULT ABUSE/NEGLECT CENTRAL REGISTRY SCREEN Background checks on volunteers, prospective employees, or an employee who has or may have unsupervised access to minors or vulnerable adults may be screened. Note: According to W.S. 14-3-214, “the applicant shall use the information received only for screening prospective employees and volunteers.” Instructions: 1) The requesting organization should complete page one of this form in ink. 2) The person being screened will complete page two of this form in ink, ensuring the Authorization of Release of Information is signed and dated. 3) Verify SSN and DOB with a driver’s license or other means of identification and obtain a copy for your records. 4) Authorization is only valid for sixty (60) days from the date signed 5) A ten dollar ($10) fee is required for each individual screened. An invoice will be sent to you after screens for the current month are complete. 6) Submit an envelope addressed to the Organization requesting the check with the request. Postage is not required but is appreciated. 7) For accuracy purposes, please attach a typed list of the names, dates of birth and social security numbers for all individuals being screened. 8) Incomplete forms and requests not accompanied by a check or money order will be returned unprocessed. 9) Only applications with original signatures will be accepted. Electronic signatures, scanned or faxed copies are not accepted. 10) The SS-26 Form will be returned to the agency requesting the screen when it is complete. 11) ¥By including an email, you acknowledge The Department of Family Services may send you results electronically, and agree to abide by all confidentiality laws regarding Central Registry data. The original will follow by mail. 12) Areas marked by an asterisks are required fields. Mail application to: Department of Family Services Central Registry 2300 Capitol Ave, 3rd Floor Cheyenne, WY 82002 Note: Central Registry screens are specific to the State of Wyoming. To be Completed by Organization/Facility (Print clearly) *Name of person being screened: *Organization requesting check: City of Cody *Contact person for requesting organization: Cindy Baker *Mailing Address: PO Box 2200 *City: Cody *State: WY *Zip: 82414 *Phone: (307) 527-7511 ¥Organization Email (optional): [EMAIL REDACTED] For Central Registry Use only Date Completed Reference Number - 0233 Person being screened listed on the DFS Abuse/Neglect Central Registry? YES NO Central Registry Specialist initials CITY OF CODY WILL PAY THIS FEE ---PAGE BREAK--- SS-26 INV 7/1/2018 Page 2 of 2 AUTHORIZATION OF RELEASE OF CHILD & ADULT ABUSE/NEGLECT CENTRAL REGISTRY INFORMATION To Be Completed by Person Being Screened (Please type or print legibly in ink.) I hereby authorize the Wyoming Department of Family Services to conduct a Wyoming Central Registry Record Search to check for abuse, neglect and exploitation of children or vulnerable adults. I agree to provide the following information and any other information needed to initiate the background check. I understand that any falsification of information or substantiated abuse or neglect activities may be the grounds for termination of employment. *Legal Name (First, Middle, Last) *Maiden Name *Former Married Names *Aliases or Nicknames *Social Security Number *Date of Birth *Gender: Male Female *Current Address *City *State *Zip *Phone *List All Addresses for the past five years “Voluntarily” List Names of Your Children (This information assures accuracy of the screen) If you do not agree to electronic submission of results to the email address listed on page 1 please opt out by initialing here. I hereby authorize the results of this check be provided to the Organization/Agency identified on Page 1 of this form. If this application is being made as a requirement of a child placing agency, therapeutic foster care, and/or an adoption agency, I hereby authorize the requesting agency to provide the results of this check to the Department of Family Services. *Signature of Person Being Screened *Date Valid for 60 Days *Pursuant to W.S. 14-3-214(f) and W.S. 35-20-116(a), any organization receiving a report that a prospective employee/volunteer is “under investigation”, shall be notified of the final determination of that investigation. A second screen result will be sent to the Organization on Page 1 when a final determination is made in these cases.