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2. APPLICANT INFORMATION
4. First Name *
5. Last Name*
7. Preferred Name
9. Address (Street Address, Apt #)*
11. City*
12. State*
13. Zip Code*
15. Is your physical address different than your mailing address? *

    1. Yes
    2. No
16. Primary Phone Number*
18. Email Address*
20. Parent(s)/Guardian(s) Name*
21. Parent/Guardian Phone *
23. Parent/Guardian Email Address*
25. Able to work ~28 hours/week during the summer?*

    1. Yes

    1. No

    Typical work week is Monday - Thursday, 8:30 a.m. - 3:30 p.m. Occasionally other opportunities for work will be available. 

27. Is there anything that would prevent you from performing the essential job functions, as described in the job description, in a reasonable and safe manner for the position for which you have applied? *

    1. Yes*

    1. No
29. *If yes, please explain.
33. EDUCATION + REFERENCE
35. Current School*
    -- Select One --ALCHempsteadSeniorWahlertOther
36. Current Age*
38. Reference Name*
    Please list one reference (a person who would recommend you for the job).
40. Relationship to Reference*
41. Reference Phone Number*
43. Reference Email Address*
45. I do not have a digital version of my reference letter.
    Link to online reference form
46. I have a digital version of my reference letter & I will upload here.
50. ACKNOWLEDGEMENTS
52. Have you been convicted of, or received a deferred adjudication for any law violation? *

    1. Yes
    2. No
53. I affirm that I live in Dubuque *

    1. Yes
55. I affirm that I will be between the ages of 19-24 on June 1, 2026.*

    1. Yes
56. I understand that I must attend the mandatory orientation and training and be available to work through the last day of the program on August 7, 2026.

    1. Yes
58. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

    1. I understand.
60. I understand that if I am applying to be a Teen Resiliency Corps Crew Lead, my application is not complete until I submit a letter of reference.*

    1. I understand.
64. Digital Signature - type name or initial*
65. Date*
    Date
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field