Interview Date:
For Office Use Only:
1. ___ ___ ___
2. ___ ___ ___
3. ___ ___ ___
Student Coordinator/Student Hourly
Application for Student Employment
INSTRUCTIONS
Student
Employment
Each question should be fully and accurately Application
answered. Use afor
blank
page if you
do not have enough room on this
form. Please print or type. Please attach a current resume and a potential available work schedule. Return the
completed application to Victoria Hare, Victoria.Hare@Colorado.Edu, in UMC 411 by 5 pm on April 1, 2016.
APPLICANT INFORMATION
Last Name
Street Address
City
Phone
I am available to start May 2016
or August 2016
Are you an undergraduate student?
EDUCATION
YES
Major
First
M.I.
Date
Apartment/Unit #
State
E-mail Address
Student ID Number
ZIP
(DO NOT LIST SSN)
NO
Projected Graduation Date
Do you have a work-study award?
YES
NO
College:
SPECIAL SKILLS AND INTERESTS
Please check area(s) of expertise/experience:
Word processing
Graphic design
Presentation software
Event Planning
Video creation
Presentation skills
Written communication
Facilitation skills
Working with a team
Time management
AV/technology equipment
Below are content areas covered by Community Health, please check the top 3 topics you are interested in working on:
Body Image/Nutrition
Health Equity
Illness Prevention
Stress Management
Overall Health Promotion
Alcohol, Tobacco, Other Drug (AOD) Awareness/Prevention
Sexual Health
WORK RELATED HISTORY
ARE YOU CURRENTLY WORKING FOR ANOTHER CU EMPLOYER?
YES
NO
If yes, department name:
All employees are required to self-disclose if they are currently working for or subsequently begin working for more than one CU
department. This includes working for an agency contracted under the off-campus work-study program.
Employer:
Address:
Name of Supervisor:
Employment Period:
From
Title and Responsibilities:
Phone
To
(
)
Phone
To
(
)
Reason for Leaving:
Employer:
Address:
Name of Supervisor:
Employment Period:
From
Title and Responsibilities:
Reason for Leaving:
SUPPLEMENTAL QUESTIONS
How would working for Community Health fit with your personal, academic, and career goals?
What do you think are the top three factors that promote health among your peers?
What do you think are the top three factors that negatively impact health among your peers?
REFERENCES
Please list two professional references.
Full Name
Company
Address
Relationship
Phone (
)
Full Name
Company
Address
Relationship
Phone (
)
ASSURANCES
I
I
I
I
I
I
am able to participate in required Monday staff meetings from 5 – 6:30 pm during the academic year. Yes
No
will be available to participate in mandatory training (early June for summer start, mid-August for fall start dates). Yes
am available to work 10-15 hours per week during the academic year. Yes
No
understand that a background check may be required as a condition of employment. Yes
No
understand I will be required to get an annual influenza vaccine. Yes
No
understand that I will not receive clinical experience as part of my employment. Yes
No
No
I certify that the answers and statements provided on this application are true and correct without consequential omissions of any kind.
By checking this box and typing my name below, I am electronically signing my application.
Signature:
Date:
The University of Colorado does not discriminate on the basis of sex in the education programs or activities it operates or in
employment. Inquiries to the University of Colorado concerning the application of Title IX and its implementing regulation may be
referred to the campus Title IX coordinator at http://hr.colorado.edu/dh/Pages/default.aspx or to Office of Civil Rights (OCR) at:
http://www2.ed.gov/about/offices/list/ocr/index.html.
DEMOGRAPHIC INFORMATION (OPTIONAL)
What is your race? (Choose one or more)
American Indian or Alaska Native
Asian
Black or African American
Are you Hispanic or Latino/a?
Native Hawaiian or Other Pacific Islander
White
Other
Yes
No