A child’s hope for a better life starts with you!

Calendar

Upcoming Events

May 18: Walk Now for Autism Speaks
July 20: 4th Annual West Coast Disability Pride Parade & Festival
August 16: San Jose Giants Disability Awareness Night (link coming soon)

Via West (Formerly Camp Costanoan) Application

Applicants for volunteer positions must be in high school (15 years of age or higher is preferred but all high school students will be considered). Applicants for staff positions must be 18 years of age or older. Please make sure to include 3 references with email addresses to enable easy contact. Thank you.

Personal Information

Name: *

Email Address: *

Current Address:

Current City:

Current State:

Current Zip:

Current Phone:

Expires:

Date Current Address Expires

Permanent Address:

Permanent City:

Permanent State:

Permanent Zip:

Permanent Phone:

Position you are Applying for:

Start Date:

Earliest date you are able to begin employment

End Date:

Latest date you are able to leave employment

Will you be 21 years of age by June 7, 2013:

Yes

If yes, do you have a clean driving record?:

Yes

Would you be willing to drive vans on field trips?:

Yes

Education and Experience

High School:

Please include name of school, year(s) completed, and any other pertinent information.

College/University:

Please include name(s) and location(s) of school(s), year(s) and degree(s) completed, and any other pertinent information.

Camping/Outdoor Education Experience:

Please include name(s) and address(es) of program(s), position(s) and responsibilities held, dates worked, and contact information for any supervisors.

Other Work Experience (Paid or Volunteer):

Please include all information about employer(s), position(s) and responsibilities held, dates worked, and any pertinent contact information.

More Information

Describe any experience (personal, volunteer or paid) with children or adults with disabilities:

Describe any experience (personal, volunteer or paid) with camping or with children:

Describe your goals and/or objective for the position for which you are applying:

What unique contribution do you personally bring to the position and the camp program:

Is there any additional information you would like us to consider when reviewing this application:

Certifications

First Aid

Standard:

Expiration Date

Advanced:

Expiration Date

Wilderness:

Expiration Date

First Aid Instructor:

Expiration Date

CPR:

Expiration Date

CPR-Professional Rescuer:

Expiration Date

CPR Instructor:

Expiration Date

EMT:

Expiration Date

Aquatics

Lifeguard:

Expiration Date

WSI:

Expiration Date

Adaptive Aquatics Instructor:

Expiration Date

Other Certifications:

Languages:

Languages applicant speaks and/or writes fluently (including Sign Language)

References:

Please list the names, contact information, and any other pertinent information of at least two professional and/or character references

Eligibility

Are you legally entitled to work in the United States: *

yes

(If you are hired you will have to present evidence of your right to work in the United States no later than three days after the commencement of your employment)

Have you ever been convicted of a crime (misdemeanor or felony): *

yes

If yes, state the nature of the crime(s), when and where convicted and disposition of the case. You may omit minor traffic offenses, any convictions which have been sealed, expunged or statutorily eradicated, convictions more than two years old for marijuana related offenses for personal use, and misdemeanors for which probation was completed and the case judicially dismissed. (Conviction of a crime will not necessarily disqualify you from employment. Such factors as time of the offense, seriousness and nature of the violation and rehabilitation will be considered.)

Release of Information

Authorization: *

yes

I hereby authorize Via Services, Inc. and its agents to check references and confirm any educational degrees. I release Via Services, Inc. and its agents from any and all liability, claims or lawsuits relating to Via Services, Inc.’s investigation and/or use of the information obtained from any and all of the above-referenced sources. I agree to defend, indemnify and hold harmless Via Services, Inc. from any and all claims or lawsuits which may result from Via Services, Inc.’s investigation or actions taken as a result of its research.

Acknowledgement: *

yes

I understand that if I am hired, I will be required to provide documents which will verify my identity and eligibility to work in the United States, in compliance with the Immigration Reform and Control Act of 1986. I understand that failure to reveal any prior employment I have had within the past ten (10) years or the providing of any false or misleading information may be grounds for immediate termination if Via Services, Inc. hires me, regardless of when Via Services, Inc. discovers the correct information. I understand that all Via Services, Inc. employees are "at will" employees. This means that if I am hired by Via Services, Inc. I may resign my employment at any time, for any or no reason. Similarly, Via Services, Inc. may terminate my employment at any time, with or without notice, for any or no reason. No promise or representation contrary to the foregoing is binding on Via Services, Inc. unless made in writing and signed by the President & CEO of Via Services, Inc.