Your Experience Counts Application
Complete each section. Those marked with an asterisk (*) are required. The form will not submit unless these fields are completed.
First Name *
Your answer
Last Name *
Your answer
Middle Name
Your answer
Gender *
Required
Primary Phone *
Your answer
Secondary Phone
Your answer
Email address *
Your answer
Please provide the NAME & HOME/WORK PHONE NUMBERS of an emergency contact: *
Your answer
Which of these locations would be reasonable driving distance for you?
What is your limit on driving distance for volunteering?
Please state drive time in MINUTES
Your answer
Are you able to commit 2+ hours IN THE CLASSROOM per week, for the duration of the school year? *
Required
We match volunteers with teachers to support the following academic areas, during the school day. Please check off the area(s) that are your strongest preference. *
Required
Availability: Please check ALL the POSSIBLE days/times you could serve in the classroom (this will not set your schedule).
We will use your availability to match you with a teacher who needs help on certain days, but you and your teacher will mutually determine your weekly days/times.
8-9am
9-10am
10-11am
11am-12pm
1-2pm
2-3pm
Monday
Tuesday
Wednesday
Thursday
Friday
Your Mailing Address (If using a PO Box, please also include a street address) *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Seasonal/Business Address (if applicable--please indicate what months of the year you are away from Arizona)
Your answer
Highest level of education completed: *
Career Area/Job Sector 1 *
In what sector have you spent the longest duration of your working life (i.e. Marketing, Social Work, Business, Engineering, Real Estate, Retail, Homemaker, Elementary Education, currently Full Time Student, etc.)?
Your answer
Career Area/Job Sector 2
In what other sector(s) have you spent a significant duration(s) of your working life?
Your answer
Your Ethnicity *
Credentials/Certifications
(NOT REQUIRED) If you have any special training or certifications (even if expired or out-of-state) that makes you highly qualified to work with elementary or middle school students, please list the TITLE(s) of those credentials below.
Your answer
References
Please exclude immediate family members. SUBMIT 3 TOTAL REFERENCES: Name & Phone # for 1-professional reference & 1-personal reference. Include 1 other, either personal or professional. (If you prefer, this information may be submitted during the interview.)
Your answer
Are you a U.S. citizen, national, or lawful permanent resident alien? *
Required
If you are a lawful permanent resident alien and you received your card after Jan. 1987, what is your registration number and card expiration date?
Your answer
Have you ever been convicted, or adjudicated as a juvenile offender, of any criminal offense by either a civilian or military court, other than a minor traffic violation? *
Required
Are you currently under charges for any offense? *
Required
Are you currently on probation or parole? *
Required
How did you hear about us? *
Required
CERTIFICATION: I certify that all of the statements made in this application are true, correct, and complete, to the best of my knowledge, and are made in good faith. I understand that misinformation or omission of information could result in disqualification and/or termination as a Your Experience Counts member. I understand that my selection for participation in the Your Experience Counts program may require a physical examination by my physician. I also give my consent for the background security check which is conducted annually for this program. *
Please initial & date: "I have read and agree to this statement."
Your answer
Thank you for applying to become a YEC member! Below are the next steps in our intake process. *
PLEASE CHECK OFF ALL ITEMS BELOW that you have NOT YET COMPLETED (this will most likely be all of them, unless you submitted paperwork at our office or an event table.)
Required
DO NOT CLOSE THIS WINDOW UNLESS YOU RECEIVE A "THANK YOU..." MESSAGE CONFIRMING THAT YOUR APPLICATION WENT THROUGH.
If the "Thank you..." message doesn't appear, scroll back through your application and fill in any questions that are marked in red.
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