Program Provider Application for Outreach
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1. Program Provider Application
Thank you for your interest in working as a Program Provider for the Girl Scouts Carolinas Peaks to Piedmont Council. The position you are applying for is a part-time, temporary (seasonal) hourly position working with our outreach Girl Scout members through community partner sites such as the Boys and Girls Club and Housing Authorities.
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1
. Name
Name
First
Middle Initial
Last
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2
. Outreach programs are conducted at community sites such as the Boys and Girls Clubs and Housing Authorities in the following cities. Which of the Girl Scouts Carolinas Peaks to Piedmont outreach sites would you like to work at?
1st Choice
2nd Choice
3rd Choice
Hickory
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Outreach programs are conducted at community sites such as the Boys and Girls Clubs and Housing Authorities in the following cities. Which of the Girl Scouts Carolinas Peaks to Piedmont outreach sites would you like to work at? Hickory 1st Choice
Hickory 2nd Choice
Hickory 3rd Choice
Gastonia
Gastonia 1st Choice
Gastonia 2nd Choice
Gastonia 3rd Choice
Asheville
Asheville 1st Choice
Asheville 2nd Choice
Asheville 3rd Choice
Winston Salem
Winston Salem 1st Choice
Winston Salem 2nd Choice
Winston Salem 3rd Choice
High Point
High Point 1st Choice
High Point 2nd Choice
High Point 3rd Choice
Greensboro
Greensboro 1st Choice
Greensboro 2nd Choice
Greensboro 3rd Choice
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3
. Current Contact Info
Current Contact Info
Current Address
City
State
Zip Code
Country
Telephone (include area code)
Current Address is valid until (mm/dd/yyyy)
4
. Permanent Contact Info (if applicable)
Permanent Contact Info (if applicable)
Current Address
City
State
Zip Code
Country
Telephone (include area code)
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5
. Present Occupation or Year In School
Present Occupation or Year In School
*
6
. Dates Available
MM
DD
YYYY
From
Dates Available From Month
/
Day
/
Year
To
To Month
/
Day
/
Year
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7
. Email Address
Email Address
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8
. How often do you check your email?
How often do you check your email?
Daily
Weekly
9
. Where did you hear about the positions available?
Where did you hear about the positions available?
Job Fair (Where?)
Newspaper (Which?)
Internet (Which Site?)
Friend/Staff Member (Who?)
Flyer (Where?)
Other (please specify)
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10
. Have you ever been convicted of a crime (other than a minor traffic violation)?
Have you ever been convicted of a crime (other than a minor traffic violation)?
Yes
No
11
. If yes, please state offense, date and location.
A conviction record will not necessarily be cause for disqualification, but failure to disclose may be.
If yes, please state offense, date and location. A conviction record will not necessarily be cause for disqualification, but failure to disclose may be.
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12
. Are you able to get yourself to and from the work site?
Are you able to get yourself to and from the work site?
Yes
No
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13
. Do you hold a current US Driver’s License?
Do you hold a current US Driver’s License?
Yes
No
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