Attention Please Read
Before Filling Out
Please ll out application using a desktop computer rather than
a cell phone.
If you are viewing this application in Internet Explorer, you can
skip the following instructions.
If you are using an internet browser other than Internet Explorer,
ke Chrome, you must perform the following:
1. Download and save the PDF form to your desktop before
lling the form out and submitting. (Any information typed
into the form will be lost.)
2. Open the saved PDF form from your desktop.
3. Fill out the PDF form completely.
4. Click on the “Submit” button at the bottom of the PDF form.
(You will then be instructed to save and email your PDF form.)
If there are any questions please email:
ank you.
Application for Lifeguard Summer Employment
Early return of this application is suggested.
The minimum age for employment is 15.
Complete all applicable elds of this application and return to: Westchester County Parks - Lifeguard Supervisor
450 Saw M
ill River Road, Ardsley, NY 10502
or email:
Personal Information
Last First Middle
Social Security Number
(Last four digits only)
Number Street City State Zip
Applicant Phone Numbers
Are you 18 years of age or older? Yes No
If not, age?
Minimum age for hire is 15
Are you a Westchester County
Resident? Yes No
Applicant’s E-mail address
High School
Name and Location Attendance Dates Course or Major Date Degree Received or Expected
College or
Business School
Graduate or
Professional School
Certicates or Special Training:
Employment History
(Last 5 Years)
Name and Location
of Employer
Kind of Work
or Position
Paid or
Reason for Leaving
Have you worked for Westchester County Government before? Yes No Which Department:
Reason for leaving:
In addition to English, are you uent in any other language? Yes No If yes, specify:
Lifeguard Certications - Must Provide (Certication and Indicate expiration date [mm/dd/yy] )
Lifeguarding/First Aid/
Lifeguarding/First Aid/
CPR/AED with
Instructors Certications
Lifeguard Management
Do you have a Drivers License? Yes No Type:
Employment as a lifeguard is contingent upon the successful completion of the Westchester County Department of
Parks, Recreation and Conservation Water Skills Test.
I am available to begin working every day beginning on: May June July August
You will be required to work weekends and the Fourth of July.
Are you available to work Full Time or Part Time? Full Time Part Time
Schedules are subject to supervisory approval.
Where did you hear about this job?
1. Were you ever dismissed or discharged from any employment for reasons other than lack of
work or funds? Yes No
2. Did you ever resign from any employment rather than face dismissal? Yes No
3. Did you ever receive a discharge from the armed forces of the United States which was
other than honorable, or which was issued for other than honorable circumstances? Yes No
If you answered “yes” to any questions above, you must give specics, including date, nature and current disposition. Email or mail to above address
an additional 8 ½ x 11 sheet. Your application will not be processed until we receive it. None of the above circumstances represents an automatic
bar to employment. Each case is considered and evaluated on individual merits in relation to the duties and responsibilities of the position(s) for
which you are applying.
All statements are subject to verication and criminal records check.
This armation must be completed:
I arm that all statements made on this application (including any attached papers) are true under the penal-
ties of perjury. (Applicants are advised that all statements made by them in connection with their application(s) for employment are subject to investi-
gation and verication.) This application may be used for review by the prospective appointing authority as part of a background investigation.
Pursuant to 210.45 of the New York State Penal Law. It is a crime punishable as a class A misdemeanor to
knowingly make a false statement herein.
By accepting employment with the County of Westchester, I hereby agree to submit to any and all forms of drug testing (such as
urinalysis, breath and/or blood testing) as a condition of Seasonal Employment in accordance with Westchester County’s
Comprehensive Drug-Free Workplace Policy and Procedures. In addition, if oered employment, I will be subject to the Westchester
County ngerprinting policy under which my appointment may be conditioned on the results of a ngerprinting investigation.
Date (mm/dd/yy):
*Typing your full name into the box to
the right is acknowledging you agree
to the above statements.
If under age 18, parent or guardian is required to read the statement below and type their full name before
application can be submitted.
“I have read my child’s or ward’s completed application form and hereby give my permission for him or her to be hired by Westchester County for
the purpose of seasonal employment and I further give my permission for him or her to receive emergency medical treatment if necessary. If at any
time I revoke this permission, I will do so in writing to the Westchester County Department of Human Resources, and upon receipt by the
Department of Human Resources of said revocation my child’s/ward’s employment shall be terminated.
By my signature below, I hereby give my permission for the applicant stated above to submit to any and all forms of drug testing (such as urinalysis,
breath, and/or blood testing) as a condition of Seasonal Employment with Westchester County in accordance with Westchester Countys
Comprehensive Drug-Free Workplace Policy & Procedures.
Date (mm/dd/yy):
*Typing your full name
and information into
the boxes to the right
is acknowledging you
agree to the above
Parent or Guardian:
Parent or Guardian Phone Number:
Parent or Guardian Email Address:
*Please note: Written signature will be required if hired.
The County of Westchester is an Equal Opportunity Employer.
Submit Application