First and Last Name

Street Address

City    State    Zip Code 

Phone Number (including area code) 

Mobile Phone Number (including area code) 

Email Address 

Date of Birth:  (mm/dd/yy) 

Primary Employment Interest  Lifeguard Manager/Assistant Manager Pool Attendant Concession Desk Attendant Head Guard Groundskeeper Swim Lesson Instructor Swim Lesson Coordinator Swim Coach Office Staff Field Supervisor

What pool(s) are you interested in working at? 

Have you worked for MPM previously?  Yes No

If so, what summer(s) did you work? 

At which pool(s) did you work? 

Are you in:  High School College Not In School   Name of School: 

What grade level in school are you?  Senior Junior Sophomore Freshman   

If you are not a student, what is your present occupation? 

Do you expect to be gone at any time between May 15 and September 5?   Yes   No

If yes, what dates? 

What is the earliest date you are available to start work? 

If you are in College, when is the last possible day you can work? 

If you are in High School, when do your classes start in the fall? 

Do you play fall sports?  Yes   No        If yes, when do practices start? 

You will be expected to work evenings and weekends once school starts.  If you are unable to do so, please explain why: 

Do you have any summer activities planned that may require a special work scheduling?  (School activities, camps, etc.)

  Yes No    If yes, please provide dates and details: 

Have you ever been certified as a lifeguard?  Yes No

If yes, please list certifications and expiration dates:

What hobbies or special interests do you have? 

How did you first hear about our company?  (Be specific): 

Please list your two most recent employers below:

Company Name:    

Name and phone number of supervisor: 

Type of work Performed: 

Are you still employed by this Company?  Yes No       

If not, what was your reason for leaving? 

Company Name:    

Name and phone number of supervisor: 

Type of work Performed: 

Are you still employed by this Company?  Yes No       

If not, what was your reason for leaving? 

Please list two references (family, friends, teachers, etc.) that you know well enough to recommend you.

Reference 1:

Name:    Address:      

Phone:     Occupation: 

Reference 2:

Name:    Address:      

Phone:     Occupation: 

Do we have permission to contact your references:  Yes No

How far would you be willing to drive to work?  (To select more than one, hold down the CTRL key while making your selections.)

  Less than 5 miles 5-10 Miles 10-20 Miles More than 20 miles Other   

If other, please explain: 

How do you plan to get to work? 

In an effort to place you at a pool as close as possible to your home, please list any pools which you know of in your area:

Are you a member at any swimming pool(s)?  Yes No     

If yes, where? 

Additional Information:

Hepatitis B. Vaccine Determination

I understand that due to my occupational exposure to blood 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.  This is not the three series shot, and will only be administered if you are exposed to infectious materials.

Please select one:  I have had the three series Hepatitis B vaccinations. I have NOT had the Hepatitis B vaccinations.  

Emergency Notification:

Name of person to notify in case of emergency:    Relationship: 

Phone Number: 

Note:  If you are a new applicant or if you are under the age of 16, you will be required to come to the office for an interview.

Note:  If you are in high school, you will be required to work evenings and weekends until Labor Day unless approved by your District Manager.

Midwest Pool Management is an Equal Opportunity Employer (M/F/V/H)