Mosholu Montefiore Community Center 3450 Dekalb Avenue Bronx, NY 10467 Phone: 718- 882-4000 • Fax: 718- 882-6369 • www.mmcc.org

MosholuRe-HirePacket-ReturningStaff-GroupA

Name:___________________E-mail:____________________

This packet is due within a week. All paperwork must be completed before you can be considered an actual employee and placed on payroll.

Thefollowingformsmustbecompleted…

_____MMCCConditionalOfferLetter

_____MosholuCampsOfferLetter

_____MMCCApplication

_____StatementofRecentExperience

_____StaffHealthForm

_____2016W4

_____UpdatedProofofEducation(indicatingschoolyear&totalcreditaccumulation)

Allreturningstaffovertheageof18willnowbeaskedtobefingerprintedbytheNYCDepartmentofEducation.Uponsubmissionofthispaperwork,youwillbeinputintothesystemandyouwillreceiveanemailfromthemwithspecifics.

Ifyourecentlyturned18yearsold……

_____SCRClearanceForm(Pleaselistalladdressesbacktobirth)

_____$25moneyordertoprocessSCRClearance

(madeouttoOCFS-OfficeofChildrenandFamilyServices)

Ifyourecentlyturned18yearsoldyouwillreceiveasupplementalpacketwithadditionalclearancesandformsallowingyoutobefingerprintedbyboththeDOEandtheNYCDOH

Placeacheckhereifyouturned18yearsofage

SINCEthebeginningoflastsummer___________

MosholuSummerStaffOfferEmployee’sName: FileNumber:PositionOffered:FullSalary:BasedOn:(FullSalaryisbaseduponattendanceatallPre-CamporientationsandfulldailyattendanceJune29-August19)DailyRate:(Thisistheamountofmoneythatwillbesubtractedfromyoursalaryforeachdayyoumiss)Yoursalaryiscalculatedbaseduponpositionassigned,employmenthistoryandrequiredproofofeducation.Shouldyourpositionchangeoryoufailtoproveeducationstatus,yoursalarywillbeadjustedaccordingly.Pay:Therewillbethreepayrollperiods.Yourfullsalarywillbedividedintothesepayperiods.Thecampwillremitpaymentbaseduponthenumberofdaysinthepayrollperiod.Thiswillbecalculatedbythenumberofdaysofattendancemultipliedbythedailyrate.AppropriatetaxeswillbedeductedbaseduponyourW4filing.Summer2016Paydaysareasfollows…… July22(12days),Aug5(10days),Aug19(15days)(Orientationdates,latenights&overnightsarerequired&arefiguredintodailyrates&NOTcalculatedseparately)Responsibilities:Yourspecificresponsibilitiesaswellasassignmentwillbediscussedatlengthduringorientationandaresubjecttochangeatthecamp’sdiscretion.Thisagreementisnotacontract.Employmentisdependentuponsubmissionofanyandallhirepacketrequiredpaperwork,whichisduebeforeemploymentbegins.Nostaffmembercanbeplacedonpayrollwithoutallpaperworksubmitted.Youwillhaveatimesheetandyouareexpectedtosigneachday. IntheeventthatMMCC,atourdiscretion,isrequiredtocloseorotherwisesuspendprogramsorindividualemploymentforanyreasonwhatsoever,thisagreementmaybeterminatedwithoutfurtherliabilityonourpart,otherthantopayyoursalaryuptothedateoftermination. Offermadeby: ____________________________________Date:________________________ _______________________________________________________ _________________________EmployeeSignature Date_______________________________________________________ __________________________Parent’sSignature(ifemployeeisunder18) Date

Welookforwardtoworkingwithyou.TogetstartedJointheMosholuDayCamp,Google+Community

https://plus.google.com/u/0/communities/108998098499828563692

Mosholu Montefiore Community Center 3450 Dekalb Avenue Bronx, NY 10467 Phone: 718- 882-4000 • Fax: 718- 882-6369 • www.mmcc.org

Dear _________________: We are pleased to extend you a conditional job offer for the position of __________________with MMCC. As per regulations set forth by the Department of Health, Department of Education, Office of Mental Health, Office of People with Development Disabilities and in accordance with guidelines set forth by the Office of Children and Family Services and Department of Youth and Community Development that govern MMCC’s programs, a criminal background check and a State Central Registry for Child Abuse/Maltreatment check must be conducted in order to continue in the hiring practice, and if hired, to your continued employment with us. Additionally, you must provide us with a minimum of three (3) employment references within three (3) days of receipt of this letter. Please complete the attached Statewide Central Register Database Check Form (LDSS – 3370) and return it along with a money order in the amount of $25. The form requires you to list your place(s) of residence for the last 28 years and there can be no gaps in your dates of residence. In addition to the Statewide Central Register Database Check, depending upon your position and the department you are assigned to, you may need to be fingerprinted by DOE or DOH and additional fees will be required. Further, in accordance with the New York City Commission on Human Rights (“NYCCHR”) Fair Chance Act 2015, please read the question below and respond accordingly. Have you ever been convicted of a misdemeanor or felony? ___ Yes or ___ No Answer “NO” if your conviction: (a) was sealed, expunged, or reversed on appeal; (b) was for a violation, infraction, or other petty offense such as “disorderly conduct;” (c) resulted in a youthful offender or juvenile delinquency finding; or (d) if you withdrew your plea after completing a court program and were not convicted of a misdemeanor or felony. Once we receive the results of your criminal record check, we will contact you if further information is required and provide you with a copy of New York Correction Law Article 23-A of the Fair Chance Act 2015. Please sign below to acknowledge receipt of this letter and return it along with your complete Statewide Central Register Database Check form (LDSS – 3370) and your $25 money order. If this letter, the LDSS – 3370 form, your money order and the three (3) employment references are not received within three (3) business days from the date of this letter, we will assume that you have declined MMCC’s conditional job offer. Sincerely,

Judith Sommerich Human Resources Director cc: Rita Santelia, Associate Executive Director Name: ____________________________________________________ Date: ________________________

APPLICATIONFOREMPLOYMENTDate:_______________________________________________________________________________________________

Position(s)ApplyingFor: ______________________________________________ BranchLocation: ______________________________________________ SalaryDesired: ______________________________________________

EqualOpportunityEmploymentPolicyMosholuMontefioreCommunityCenteranditsaffiliatescomplieswithallfederal,stateandcityequalopportunityandanti-discriminationstatutes.MMCCiscommittedtoapolicythatguaranteesthetreatmentofallemployeesandapplicantsforemploymentwithoutunlawfuldiscriminationastorace,creed,color,nationalorigin,sex,age,disability,maritalstatus,sexualorientationorcitizenshipstatusinallemploymentdecisions,includingbutnotlimitedtorecruitment,hiring,compensation,trainingandapprenticeship,promotion,upgrading,demotion,downgrading,transfer,lay-offandtermination,andallothertermsandconditionsofemployment.Reasonableaccommodationswillbemadeforapplicantsandqualifiednewlyhiredemployees.

EmploymentAvailabilityWhattypeofpositionareyoulookingfor:____FullTime____RegularPartTime____Seasonal____Other?

Whenareyouavailable?(Checkallthatapply):___Mornings___Days____Evenings___LateEvenings___Weekends

Ifhired,onwhatdatewillyoubeavailabletostartwork:______________________

Arethereanyrestrictionstothehoursyouareavailabletowork?_______Yes________No

Howdidyoulearnaboutthisopening?

☐ SignsatCenter ☐ Relative☐ Webpage ☐ Employee☐ Referral ☐ EmploymentAgency☐ Advertisement ☐ Other☐ Walkin

AdditionalInformation OtherRelevantCertificationsHeldDoyouholdyourCPRcertification?

___YesExp.Date:

___No

Type:

Expiration:

DoyouholdyourcurrentFirstAidcertification?

___YesExp.Date:

___No

Type:

Expiration:

DoyouholdyourcurrentLifeguardcertification?

___YesExp.Date:

___No

Type:

Expiration:

MosholuMontefioreCommunityCenter(MMCC)andAffiliateCorporations

PersonalData

Name______________________________________ HomePhone_______________________________

Address______________________________________ CellPhone_______________________________

City,State,Zip_________________________________ EmailAddress______________________________

Areyou18yearsofageorolder?☐ Yes☐ NoIfyouansweredno,youwillberequiredtofurnishworkingpapersifhired.

Haveyouworkedwithusbefore?☐Yes☐NoHaveyoureceivedservicesfromMMCCinthepast?Ifyes,whichservices?________________________________

Areyoueligibletoworkinthiscountry?☐ Yes☐ No�Yes�No

References–Listatleast3references/personsthatknowyouwellandcanattesttoyourabilitiesandsuitabilityforMMCCemployment.Onereferencemustbeaclosefamilymember.

Name PhoneNumber Relationshiptoyou YearsKnown

EducationalBackground:

TypeofSchool

NameandAddress #ofyearsattended

Graduated Degree CourseorMajor

HighSchool

�Yes�No

College

�Yes�No

Graduate/Professional

�Yes�No

Business/Trade

�Yes�No

Other

Summarizeanyoutstandingachievementsorhonors:

Describeskills,education,trainingandexperiencerelevanttoworkingatMMCC:

MilitaryServiceRecord:

Haveyouservedinthearmedforces?�Yes�No

Ifyes,Whatbranch? Rankatdischarge:

Datesofduty: From(Month,Date,Year) To(Month,Date,Year)

Whatwereyourduties(includingspecialtraininganddutystation?

PriorWorkHistory&Volunteer:

Dates NameandAddressofEmployer

RateofPay Supervisorsname,titleandphonenumber

Reason(s)forLeaving

PermissiontocontactFrom To Start Finish

�Yes�No

Describeindetailtheworkyoudid?

Dates NameandAddress

ofEmployerRateofPay Supervisorsname,titleand

phonenumberReason(s)for

LeavingPermissiontocontactFrom To Start Finish

�Yes�No

Describeindetailtheworkyoudid?

Dates NameandAddressofEmployer

RateofPay Supervisorsname,titleandphonenumber

Reason(s)forLeaving

PermissiontocontactFrom To Start Finish

�Yes�No

Describeindetailtheworkyoudid?

Non-EmploymentRecord(Includeexplanationofalllapsesinemploymentonyourapplicationandresume)

From:

To:

Reason:

Dates NameandAddressofEmployer

RateofPay Supervisorsname,titleandphonenumber

Reason(s)forLeaving

PermissiontocontactFrom To Start Finish

�Yes�No

Describeindetailtheworkyoudid?

ApplicantStatement

IcertifythatallinformationIhaveprovidedinordertoapplyforandsecureworkwithMosholuMontefioreCommunityCenter(MMCC)istrue,completeandcorrect.Iunderstandthatanyinformationprovidedbymethatisfoundtobefalse,incompleteormisrepresentedinanyrespect,willbesufficientcauseto(1)cancelfurtherconsiderationofthisapplication,or(2)immediatelydischargemefromMMCC’sservice,wheneveritisdiscovered.Initial_____Iexpresslyauthorize,withoutreservation,MMCC,itsrepresentatives,employeesoragentstocontactandobtaininformationfromallreferences(personalandprofessional),employers,publicagencies,licensingauthoritiesandeducationalinstitutionsandtootherwiseverifytheaccuracyofallinformationprovidedbymeinthisapplication,resumeorjobinterview.Initial_____IherebywaiveanyandallrightsandclaimsImayhaveregardingtheMMCC,itsagents,employeesorrepresentatives,forseeking,gatheringandusingsuchinformationintheemploymentprocessandallotherpersons,corporations,organizationsforfurnishingsuchinformationaboutme.IamawarethatIhavetherighttomakeawrittenrequestfordisclosureofthenatureandscopeofanyreportthatmaybeordered.Initial_____ Iunderstanduponofferofemployment,MMCCwillconductacriminalbackgroundcheckpriortoandduringmyemploymentaswellasachildabuseregistrycheckandIamsubjecttorandom,accidentfollow-up,andforcausedrugtesting,aswellaspostofferdrugscreeningcontingentonemployment.Initial_____ IunderstandthatMMCCdoesnotdiscriminateinhiringoremploymentonthebasisofrace,color,veteran'sstatus,religiouscreed,nationalorigin,sex,ancestry,orage;oronthebasisofahandicapnot limitingtheapplicant'sabilitytoperformsatisfactorilythejobavailable.TheMMCCwillgivethisapplicationeveryreasonableconsideration.However,inacceptingit,theMMCCmakesnocommitmentofemploymenttotheapplicant.Initial_____Iunderstandthatthisapplicationremainscurrentforonly60days.Attheconclusionofthattime,ifIhavenotheardfromtheMMCCand stillwish tobeconsidered foremployment, itmaybenecessary to reapplyand fill outanewapplication.Initial_____UnlesscoveredunderaCollectiveBargainingAgreement,IunderstandemploymentwiththeMMCCisemploymentatwillwhichmeansthatemployeesmayendtheiremploymentatanytime,foranyreason;andMMCCmayterminateemployeesatanytimeforanyreason,withorwithoutcause.Initial_____IunderstandthatifIamhired,IwillberequiredtoprovideproofofidentityandlegalauthoritytoworkintheUnitedStatesandthatfederalimmigrationlawsrequiremetocompleteanI-9Forminthisregard.Initial_____IcertifythatIhaveread,fullyunderstandandacceptalltermsoftheforegoingapplicantstatement.Donotsignuntilyouhavereadandinitialedtheabovestatements.

SignatureofApplicantDate SignatureofParent(ifapplicantisunder18yearsold)FORMMCCUSEONLY

DateReceived Referredto Date

DateContacted Referredto Date

Comments

ReturningStaffStatementofRecentExperience

Pleaselistanyemploymentthatyouhadsincetheendoflastsummer.Besuretoincludethenameoftheemployeranddates…________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Pleaselistanyvolunteerexperiencesthatyoumayhavebeeninvolvedwithsincetheendoflastsummer.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Pleaselistanyrecenteducationalactivitiesorprojectsyoumayhavecompletedorbeeninvolvedinatschool.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Isthereanythingelsethatyoufeelweshouldknowabout?______________________________________________________________________________________________

RAY AND CHARLES NEWMAN BUILDING • 3450 DEKALB AVENUE • BRONX NY 10467 TEL: (718) 882-4000 • FAX: (718) 882-6369 • WWW.MMCC.ORG

MOSHOLU DAY CAMPS

STAFF HEALTH HISTORY FORM

Please Print

Name:

Home Address: APT:

Home Phone: ( )

Cell Phone: ( )

---------------------------------------------------------------------------------------------------------------------

In Case of Emergency Contact: Name:

Home Phone: Cell Phone:

Work Phone: Relationship: ---------------------------------------------------------------------------------------------------------------------

Consent for Emergency Medical Treatment I hereby give permission to the medical personnel selected by Mosholu Day Camp to order tests and/or treatment for me or my child if felt to be necessary. If I cannot be reached in an emergency concerning my child, I hereby give permission to the physician selected by the Camp to secure proper treatment for me, or my child as named above. This form may be photocopied for use out of camp.

Employee Signature: Date:

\

Parents Signature if Employee is under 18 years Date Print Parent Name: Parent Cell Phone:

PAST MEDICAL HISTORY

Dates and nature of any serious injury that may impact your summer experience: Please indicate any further information about your health needs that you feel we should know

(restrictions, special needs, etc.):

Please share any medications you may be taking that could impair your ability to perform the

essential functions of your position (i.e., Ability to work in the sun, etc.):

Do you have any physical, or emotional/psychological needs that will require reasonable

accommodation while at camp?____________________________________________________

Have you had any recent hospitalizations? If so, include dates of and reasons for hospitalization:

List any allergies (i.e.,. prescription, food, insect, etc.):

Describe allergic reaction and management of reaction:

Date of last Tetanus Shot: (Give Month and Year)

This health history is correct and complete to the best of my knowledge.

Staff Signature:

Date:

Parent Signature (if Staff member is under 18 years):

__________________________________________________

Attach Resume Here! Your resume MUST include any child care experience beyond babysitting. It should also include dates of education and employment

Attach Proof of Education Next! Your proof of education must include the current amount of credits that you have finished or diploma. A Bursar’s receipt does not demonstrate the amount of credits. If you are in high school, please include a report card or letter from your guidance counselor. Our pay scale is directly related to education. Your salary will be based upon the level of education that you demonstrate in this section.

Attach Working Papers Next! If you are under 18 years of age, you must have working papers. Please attach them to your packet.

Onlycompletethefollowingformsifyouhaveturned18sinceyouhandedinyourlastemploymentpacket.Ifwedonothavetheseformsonfile,youwillbecalledintofillthemoutinouroffice.Failuretodosowillresultinadelayofemploymentandpayrollstatus.

LDSS-3370 (Rev. 04/2011) FRONT

NEW YORK STATE OFFICE OF CHILDREN AND FAMILY SERVICES

STATEWIDE CENTRAL REGISTER DATABASE CHECK Agency Use Only

SCR USE ONLY REQUEST I.D.:

ALL INFORMATION MUST BE COMPLETE. PLEASE PRINT OR TYPE AGENCY CODE:

RESOURCE I.D. (RID)

CHILD CARE FACILITY SYSTEM (CCFS) NUMBER:

CATEGORY USE ALPHA CODE:

PHONE NUMBER (Area Code):

( ) - PRINT BELOW THE ADDRESS ASSOCIATED WITH YOUR RID/CCFS NUMBER: The particular classifications of persons who must or may be

screened are set forth on the reverse side of this document. The alpha codes to complete the “Category” box above are also on the reverse side of this form

FOR ALL CATEGORIES: Complete the following for yourself, your spouse, your children and any other person(s) in your home at the present time. MAKE SURE YOU COMPLETE ALL MAIDEN NAME/ALIAS SECTIONS THAT APPLY. IF NONE, STATE “NONE” List RELATIONSHIP in the fields below

(see reverse side for instructions) Attach additional page if necessary.

AGENCY NAME:

AGENCY LIAISON:

STREET ADDRESS:

CITY: STATE: ZIP CODE:

The purpose of collecting the demographic data on other persons in your household who are not screened pursuant to Section 424-a of the Social Services Law is to enable the N.Y.S. Office of Children and Family Services to identify with the greatest degree of certainty whether the person(s) being screened is the subject of an indicated child abuse or maltreatment report. The utilization of this information in a discriminatory manner is contrary to the Human Rights Law.

APPLICANT/HOUSEHOLD MEMBER AREA *PLEASE TYPE OR PRINT CLEARLY

RELATIONSHIP TO APPLICANT

LAST NAME FIRST NAME SEX M/F

DATE OF BIRTH

APPLICANT

MAIDEN/ALIAS

Please provide your current address and any other addresses at which you have resided for the last 28 years, including street, city and state. For Adoption, Foster Care, Family and Group Family Day Care, also include the same address history for household members 18 of age and older.

CURRENT STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM

TO

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM

TO

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM

TO

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM

TO

PREVIOUS STREET ADDRESS

APT #

CITY

STATE

ZIP

FROM

TO

I affirm that all the information provided on this form is true to the best of my knowledge. I understand that if I knowingly give false statements, such action could be grounds for denial or dismissal from employment or denial or revocation of a license, certificate, permit, registration or approval. APPLICANT’S SIGNATURE DATE

APPLICANT’S SIGNATURE DATE

EIGHTEEN YEARS OLD OR OVER: I understand that as a person eighteen years of age or over in a home of an applicant to become an Adoptive or a Foster Parent or a Family or Group Family Day Care provider, the information I have provided will be used to inquire of the Statewide Central Register to determine if I am the subject of an indicated report of child abuse or maltreatment. SIGNATURE DATE

SIGNATURE DATE

National Background Investigations, Inc.

Corporate Telephone ~ 410-604-6200 www.nationalbackground.com

APPLICANT RELEASE AND AUTHORIZATION FORM I hereby authorize Department of Human Resources or authorized

representatives of to obtain any information

pertaining to my background, including an investigative consumer report, to include

any of the searches below, including the release of worker’s compensation records for employment or volunteer purposes I hereby acknowledge that I have read and signed the attached notice and acknowledgement regarding background investigation.

APPLICANT SIGNATURE

APPLICANT NAME (PRINTED):

DATE

APPLICANT INFORMATION

First Name Middle Name Last Name

ALIAS INFORMATION

First Name Middle name Last Name

OTHER INFORMATION

Date of Birth

Social Security Number

Drivers License Number

State of Issue

CURRENT ADDRESS

Street/City/State/Zip code

Date From: Date To:

AboutFingerPrinting

As of the summer of 2016, camp employees must be finger printed by both the Dept. of Health and the Dept of Education. Upon turning in your packet we will schedule you for DOH finger printing. We will contact you to let you know when your appointment is. We will also be submitting your information for DOE fingerprinting. They will contact you directly by email with a window of time upon which you will have to go and get your fingerprints done.

Those employees whom have already been finger printed must obtain proof of finger printing and submit it rather than going through the process again. Any current after school employees can find their finger printing receipt in their folder. Simply copy that receipt and submit it with this packet. It is the responsibility of the employee to obtain this and any other copy needed to complete this packet. New employees or those whom have not yet been fingerprinted, upon completion of this form & submission of the completed packet, an appointment will be made for you. It is imperative that you adhere to that time and return the receipt as evidence of the appointment, to your supervisor immediately. If you have a preference as to dates or times for appointments, please be sure to attach a note to the form. Please make sure that you bring appropriate ID (as stated on the form) to the appointment

NYS Justice Center for the Protection of People with Special Needs (Justice Center) Criminal Background Check Unit 161 Delaware Avenue Delmar, NY 12054 Fax: 518-549-0464

Request for Staff Exclusion List Check Form

The Justice Center maintains a Vulnerable Persons Central Register (VPCR) that includes a Staff Exclusion List (SEL) containing the names of individuals who have committed serious acts of abuse and are deemed ineligible to work in a position involving regular and substantial contact with a service recipient. Providers must request the Justice Center to conduct a check of the SEL before determining whether to hire or otherwise allow “any person” to have regular and substantial contact with a service recipient. “Any person” can include an employee, administrator, consultant, intern, volunteer, or contractor. Instructions: 1. The provider’s Authorized Person must complete this form and fax it to the Justice Center’s Criminal Background Check (CBC) unit for an applicant under serious consideration to be hired or otherwise permitted to have regular and substantial contact with a service recipient. 2. The Justice Center’s CBC unit will send the Authorized Person an email indicating the results of the SEL check. 3. If the Applicant is on the SEL, he or she may not be hired in a position involving regular and substantial contact with a service recipient in a facility or provider agency defined in Social Services Law §488(4) or by other providers of services in programs licensed or certified by the Office of Mental Health, Office for People With Developmental Disabilities, Office of Alcohol and Substance Abuse Services, Office of Children and Family Services, Department of Health and State Education Department. 4. If the Applicant is on the SEL, certain other providers have discretion whether to hire the individual as provided in Social Services Law §495(3). 5. If the Applicant is not on the SEL, a criminal background check through the Justice Center, if required, and an inquiry of the Statewide Central Register of Child Abuse and Maltreatment through the Office of Children and Family Services, if required, must be conducted. Part 1. Applicant Information (Please Print) Last Name: First

Name: MI:

Date of Birth: Social Security Number: Alien Reg#: Applicant address: Applicant type:

Facility/Provider Name: Address: State Oversight Agency: OMH OPWDD OCFS DOH SED OASAS Please circle appropriate agency(ies)

Part 2. Authorized Person Information Please print clearly Name: (Please Print)

Email:

Signature: Phone:

Facility/Provider name:

Address:

JC CBC 3 (7/13)

Entered:_______________________________________

PERSONNELELIGIBILITYTRACKINGSYSTEM

(PETS)LASTNAME:FIRSTNAME;SOCIALSECURITY:DATEOFBIRTH;PRIMARYPHONE;HOMEADDRESS:CITY:STATE:ZIPCODE:COUNTY:AREYOUACURRENTDOEEMPLOYEE(YESORNO)IFSO,CURRENTTITLE:MMCCSITE:MMCCTITLE: