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Employee Onboarding Checklist


Academic year: 2021

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Revised 03.2014

Employee Onboarding Checklist

New Hire


Candidates Name

: ______________________________________

Fund Time ID #________

Primary Position Title

: __________________________________________________________

The Pre-Employment Information Checklist has been approved by HR

Attach the following documents:

** Employee will not be able to work if any of the following are missing or incorrect**

Personnel Information Form

I9 Form

(include copies of employee’s current identification forms- supervisor must be

presented with original documents from employee)

W-4 Form

Missouri State Tax Form

Direct Deposit Form

Equal Employment Opportunity Survey (Voluntary)

Employee Handbook Acknowledgement Form

Electronic Communication Policy

Child Abuse Reporting Procedures

Staff Code of Conduct

Background Check Deduction Authorization

AmericanChecked, Inc. Disclosure & Release form

Family Care Safety Registry Disclosure & Release


Scan all documents to newhire@orymca.org

Send ALL original copies to HR (do not leave any identification documents of an

employee on site)

Supervisor Name: ____________________________ Extension: ___________

Signature: __________________________________ Date: _______________

The Employee Onboarding Checklist must be scanned to newhire@orymca.org within 24 hours of the onboarding session. An email will be sent once the employee is approved to continue working. If the

employee is not approved – they must be taken off the schedule until approved. Thank you!

For HR:


Hire Date:



Emergency Contact Name Relationship Phone Number

( )


For Rehires Only:

Previously Enrolled in Retirement Fund?




Date of Termination

Emergency Contact Name Relationship Phone Number

( )


For Rehires Only:

Previously Enrolled in Retirement Fund?




Date of Termination

Ozarks Regional YMCA



- -




Employee ID #:

First Name Middle Name Last Name Maiden Name

Street Address Line 1

Street Address Line 2

City State


Zip Code Phone Number

( )


Sex (M/F) Marital Status (circle) Ethnicity

Education Level

Married Single 1-Black 2-Hispanic 3-Asian 4-Amer. Indian 5-White 6-Other 01-12 Highest Grade, HS - Graduated High School or GED, AS-Assoc. Degree,

C1-C4 Highest College Year, BS/BA/MA/PH-Degree Attained

Email Address

Employee Signature:


Supervisor Signature:


For Internal Use Only:

Circle Positions Dept./Center GL Position Code Exempt Salary Hourly Wage Ending Date (if Temp.) Sch. Hours

Exempt Nonexempt Primary









Form W-4 (2014)

Purpose. Complete Form W-4 so that youremployer can withhold the correct federal incometax from your pay. Consider completing a newForm W-4 each year and when your personal orfinancial situation changes.

Exemption from withholding. If you areexempt, complete only lines 1, 2, 3, 4, and 7and sign the form to validate it. Your exemptionfor 2014 expires February 17, 2015. SeePub. 505, Tax Withholding and Estimated Tax.

Note. If another person can claim you as adependent on his or her tax return, you cannot claim exemption fromwithholding if your income exceeds $1,000and includes more than $350 of unearnedincome (for example, interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:

• Is age 65 or older, • Is blind, or

• Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

The exceptions do not apply to supplemental wages greater than $1,000,000.

Basic instructions. If you are not exempt,complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjustyour withholding allowances based on itemized deductions, certain credits, adjustments toincome, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

Head of household. Generally, you can claimhead of household filing status on your taxreturn only if you are unmarried and pay morethan 50% of the costs of keeping up a homefor yourself and your dependent(s) or otherqualifying individuals. See Pub. 501,Exemptions, Standard Deduction, and FilingInformation, for information.

Tax credits. You can take projected taxcredits into account in figuring your allowablenumber of withholding allowances. Credits forchild or dependent care expenses and thechild tax credit may be claimed using the Personal Allowances Worksheet below. SeePub. 505 for information on convertingyour other credits into withholding allowances.

Nonwage income. If you have a large amountof nonwage income, such as interest ordividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity iincome, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.

Two earners or multiple jobs. If you have a working spouse or more than one job, figurethe total number of allowances you are entitledto claim on all jobs using worksheets from onlyone Form W-4. Your withholding usually willbe most accurate when all allowances areclaimed on the Form W-4 for the highestpaying job and zero allowances are claimed onthe others. See Pub. 505 for details.

Nonresident alien. If you are a nonresidentalien, see Notice 1392, Supplemental FormW-4 Instructions for Nonresident Aliens, before completing this form.

Check your withholding. After your Form W-4takes effect, use Pub. 505 to see how theamount you are having withheld compares toyour projected total tax for 2014. See Pub.505, especially if your earnings exceed$130,000 (Single) or $180,000 (Married).

Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4. Personal Allowances Worksheet (Keep for your records.)

A Enter “1” for yourself if no one else can claim you as a dependent . . . A B Enter “1” if:


• You are single and have only one job; or

• You are married, have only one job, and your spouse does not work; or . . . • Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.


B C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more

than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . C D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . D E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . E F Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)

G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $65,000 ($95,000 if married), enter “2” for each eligible child; then less “1” if you have three to six eligible children or less “2” if you have seven or more eligible children.

• If your total income will be between $65,000 and $84,000 ($95,000 and $119,000 if married), enter “1” for each eligible child . . . G H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) ▶ H

For accuracy,

complete all worksheets

that apply.


• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2.

• If you are single and havemore than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.

• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.



Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate

Whether you are entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074



1 Your first name and middle initial Last name

Home address (number and street or rural route) City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

4 If your last name differs from that shown on your social security card, check here. You must call 1-800-772-1213 for a replacement card. 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5

6 Additional amount, if any, you want withheld from each paycheck . . . 6 $ 7 I claim exemption from withholding for 2014, and I certify that I meet both of the following conditions for exemption.

• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and

• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write “Exempt” here . . . ▶ 7

Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature

(This form is not valid unless you sign it.) ▶ Date

8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)


Form W-4 (2014) Page 2 Deductions and Adjustments Worksheet

Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

1 Enter an estimate of your 2014 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1950) of your income, and miscellaneous deductions. For 2014, you may have to reduce your itemized deductions if your income is over $305,050 and you are married filing jointly or are a qualifying widow(er); $279,650 if you are head of household; $254,200 if you are single and not

head of household or a qualifying widow(er); or $152,525 if you are married filing separately. See Pub. 505 for details . . . . 1 $

2 Enter:


$12,400 if married filing jointly or qualifying widow(er) $9,100 if head of household . . . . $6,200 if single or married filing separately


2 $ 3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . 3 $

4 Enter an estimate of your 2014 adjustments to income and any additional standard deduction (see Pub. 505) 4 $ 5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to Withholding Allowances for 2014 Form W-4 worksheetin Pub. 505.) . . . 5 $

6 Enter an estimate of your 2014 nonwage income (such as dividends or interest) . . . 6 $

7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . 7 $

8 Divide the amount on line 7 by $3,950 and enter the result here. Drop any fraction . . . 8

9 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10 Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.) Note. Use this worksheet only if the instructions under line H on page 1 direct you here. 1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than “3” . . . 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . 3

Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additionalwithholding amount necessary to avoid a year-end tax bill. 4 Enter the number from line 2 of this worksheet . . . 4

5 Enter the number from line 1 of this worksheet . . . 5

6 Subtract line 5 from line 4 . . . 6

7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $

8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $ 9 Divide line 8 by the number of pay periods remaining in 2014. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2014. Enter

the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $ Table 1

Married Filing Jointly If wages from LOWEST

paying job are—

Enter on line 2 above $0 - $6,000 0 6,001 - 13,000 1 13,001 - 24,000 2 24,001 - 26,000 3 26,001 - 33,000 4 33,001 - 43,000 5 43,001 - 49,000 6 49,001 - 60,000 7 60,001 - 75,000 8 75,001 - 80,000 9 80,001 - 100,000 10 100,001 - 115,000 11 115,001 - 130,000 12 130,001 - 140,000 13 140,001 - 150,000 14 150,001 and over 15 All Others If wages from LOWEST

paying job are—

Enter on line 2 above $0 - $6,000 0 6,001 - 16,000 1 16,001 - 25,000 2 25,001 - 34,000 3 34,001 - 43,000 4 43,001 - 70,000 5 70,001 - 85,000 6 85,001 - 110,000 7 110,001 - 125,000 8 125,001 - 140,000 9 140,001 and over 10 Table 2 Married Filing Jointly

If wages from HIGHEST

paying job are— Enter on line 7 above $0 - $74,000 $590 74,001 - 130,000 990 130,001 - 200,000 1,110 200,001 - 355,000 1,300 355,001 - 400,000 1,380 400,001 and over 1,560 All Others If wages from HIGHEST

paying job are—

Enter on line 7 above $0 - $37,000 $590 37,001 - 80,000 990 80,001 - 175,000 1,110 175,001 - 385,000 1,300 385,001 and over 1,560

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide thisinformation; your employer uses it to determine your federal income tax withholding.Failure to provide a properly completed form will result in your being treated as a singleperson who claims no withholding allowances; providing fraudulent information maysubject you to penalties. Routine uses of this information include giving it to theDepartment of Justice for civil and criminal litigation; to cities, states, the District ofColumbia, and U.S. commonwealths and possessions for use in administering their taxlaws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose thisinformation to other countries under a tax treaty, to federal and state agencies toenforce federal nontax criminal laws, or to federal law enforcement and intelligenceagencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.


1. Allowance For Yourself: Enter 1 for yourself if your filing status is single, married, or head of household. ... 1

2. Allowance For Your Spouse: Does your spouse work? r Yes r No If yes, enter 0. If no, enter 1 for your spouse .... 2

3. Allowance For Dependents: Enter the number of dependents you will claim on your tax return. Do not claim yourself

or your spouse or dependents that your spouse has already claimed on his or her Form MO W-4. ... 3

4. Additional Allowances: You may claim additional allowances if you itemize your deductions or have other state tax

deductions or credits that lower your tax. Enter the number of additional allowances you would like to claim. ... 4 5. Total Number Of Allowances You Are Claiming: Add Lines 1 through 4 and enter total here. ... 5 6. Additional Withholding: If you expect to have a balance due (as a result of interest income, dividends, income from a part-time job, etc.) on your tax return, you may request your employer to withhold an additional amount of tax from each pay period. To calculate the amount needed, divide the amount of the expected balance due by the number of pay periods in a year. Enter the additional amount to be withheld each pay period here. ... 6 $ 7. Exempt Status: If you had a right to a refund of all of your Missouri income tax withheld last year because you had no

tax liability and this year you expect a refund of all Missouri income tax withheld because you expect to haveno tax

liability, write “Exempt” on Line 7. See information below. ... 7 8. If you meet the conditions set forth under the Servicemember Civil Relief Act, as amended by the Military Spouses Residency Relief Act and have no Missouri tax liability, write “Exempt” on line 8. See information below. ... 8

This certificate is for income tax withholding and child support enforcement purposes only. Type or print.

Notice To Employer: Within 20 days of hiring a new employee, send a copy of Form MO W-4 to the Missouri Department of Revenue, P.O. Box 3340, Jefferson City, MO 65105-3340 or fax to (573) 526-8079. Visit www.dss.mo.gov/cse/newhire.htmfor additional information regarding new hire reporting.

Employee Information —You Do Not Pay Missouri Income Tax on all of the Income You Earn! Visit http://www.dort.mo.gov/tax/calculators/withhold/ to try our online withholding calculator.

Form MO W-4 is completed so you can have as much “take-home pay” as possible without an income tax liability due to the state of Missouri when you file your return. Deductions and exemptions reduce the amount of your taxable income. If your income is less than the total of your personal exemption plus your standard deduction, you should mark “Exempt” on Line 7 above. The following amounts of your annual Missouri adjusted gross income will not be taxed by the state of Missouri when you file your individual income tax return.

• If your filing status is married filing combined and your spouse works, do not claim an exemption on Form MO W-4 for your spouse.

• If you and your spouse have dependents, please be sure only one of you claim the dependents on your Form MO W-4. If both spouses claim the dependents as an allowance on Form MO W-4, it may cause you to owe additional Missouri income tax when you file your return. • If you have more than one employer, you should claim a smaller number

or no allowances on each Form MO W-4 filed with employers other than your principal employer so the amount withheld will be closer to your amount of total tax.

• If you itemize your deductions, instead of using the standard deduction, the amount not taxed by Missouri may be a greater or lesser amount. • If you are claiming an “Exempt” status due to the Military Spouses Residency Relief Act you must provide one of the following to your employer: Leave and Earnings Statement of the non-resident military servicemember, Form W-2 issued to the nonresident military servicemember, a military identification card, or specific military orders received by the servicemember. You must also provide verification of residency such as a copy of your state income tax return filed in your state of residence, a property tax receipt from the state of residence, a current drivers license, vehicle registration or voter ID card.

Items to Remember:



Employer’s Name Employer’s Address

City State Zip Code

Date Services for Pay First Performed by Employee (MM/DD/YYYY) Federal Employer I.D. Number Missouri Tax Identification Number | | | | | | | | | | | | | | |

__ __ / __ __ / __ __ __ __

Full Name Social Security Number Filing Status

Home Address (Number and Street or Rural Route) City or Town State Zip Code

Single r Married r Head of Household r

Under penalties of perjury, I certify that I am entitled to the number of withholding allowances claimed on this certificate, or I am entitled to claim exempt status.






Employee’s Signature (Form is not valid unless you sign it) Date (MM/DD/YYYY)

__ __ / __ __ / __ __ __ __ Form

MO W-4

Missouri Department of Revenue

Employee’s Withholding Allowance Certificate

Mail to: Taxation Division Phone: (573) 751-8750 P.O. Box 3340 Fax: (573) 526-8079

Jefferson City, MO 65105-3340 E-mail: withholding@dor.mo.gov

Visit www.dss.mo.gov/cse/newhire.htm

for additional information.

Form MO W-4 (Revised 02-2014) Single

$2,100 — personal exemption $6,200 — standard deduction $8,300 — Total

+ $1,200 for each dependent + up to $5,000 for federal tax

Married Filing Combined $ 4,200 — personal exemption $12,400 — standard deduction

$16,600 — Combined Total (For both spouses) + $1,200 for each dependent

+ up to $10,000 for federal tax

Head of Household $ 3,500 — personal exemption $ 9,100 — standard deduction $12,600 — Total

+ $1,200 for each dependent + up to $5,000 for federal tax

Reset Form

Print Form


Ozarks Regional YMCA



Name Employee ID # _

Financial Institution

Financial Institution Routing Number


Account # Percent/Amount:

Standard Savings

Account #


Must attach a voided check or documentation from Financial

Institution verifying account number and routing number

If depositing in to multiple financial institutions, must complete separate form for each financial institution.

I authorize you and the Financial Institution listed above to initiate deposits of funds to which I am entitled automatically to my account. If funds to which I am not entitled are deposited to my account, I authorize you to initiate debit entries and adjustments to return said funds. This authority will remain in effect until I have cancelled it in writing at such time and in such manner as to afford you a reasonable opportunity to act.


Signature: ______________________________________ Date: _______________

Return completed form directly to Payroll


Equal Employment Opportunity Voluntary Self-Identification

Employee Survey

Our organization is an equal opportunity employer and does not discriminate in hiring or employment on the basis of race, color, religion, sex, national origin, age, disability or any other basis prohibited by federal, state or local law. No question on this form is intended to secure information to be used for such discrimination.

Our organization is required by federal regulations to report information as requested below. Your contribution of this information is completely voluntary. The information you provide is strictly confidential and will be maintained separate from your personnel file.


Current Position: ______________________________________Date: ___________

Please check one: Male Female EEO CLASSIFICATION

Mark only one:

I decline to disclose

White (Not of Hispanic Origin) Asian or Pacific Islander American Indian or Alaskan Native Black (Not of Hispanic Origin)

Hispanic Two or more races (Not Hispanic or Latino) Regulations issued by the U.S. Department of Labor with respect to handicapped individuals, disabled veterans, and Vietnam era veterans require that federal contractors provide a self-identification opportunity to applicants for employment. Such self- identification and any information provided by the applicant is submitted (a) on a voluntary basis, (b) on a confidential basis, (c) for use only in accordance with regulations, and (d) without subjecting the individual to adverse treatment. If you wish to be identified, please provide any information you wish to submit. If an applicant or employee so identifies himself or herself, the company shall seek the advice of the applicant or employee regarding proper placement and appropriate accommodation.

Yes No Recently Separated Veteran – A “recently separated veteran” is defined as a veteran

who has been discharged or released from active duty within the past three-year period.

Yes No Eligible Veteran – An “eligible veteran” is defined as a veteran who received service medals

for active duty in a military operation or campaign badges for active duty in a war, campaign, or other expedition.

Yes No Disabled Veteran – A “disabled veteran” is an individual who is rated under Veterans

Administration rules as having a disability of 30% or more, or a disability of 10% or 20% that qualified as a serious employment handicap, or has been released from active duty under a service connected disability.

Yes No Disabled Individual – A disabled individual is defined as an individual who has a mental or

physical impairment which substantially limits one or more major life activities, has a record of such impairment, or who is perceived as having such impairment.


YMCA Employee Handbook Acknowledgement

By signing below, I acknowledge that I have been provided access to the YMCA











I acknowledge that I do know how to access the

site and the Handbook and related YMCA policies. I acknowledge that it is my

responsibility to contact my supervisor or a Human Resources representative for

clarification about anything I do not understand.

I also understand that it is my responsibility to comply with all Ozark Regional YMCA

policies, rules and regulations as set forth in this Handbook, including any subsequent

additions or modifications and/or rules and regulations that the YMCA may otherwise

establish from time to time at its sole discretion. I also understand that the contents of

this Handbook may be changed by the YMCA at any time, either with or without notice. I

understand that policy updates will be posted on the intranet. It is my responsibility to

review and understand all new policies.

I further understand and acknowledge that this Handbook provides guidelines and

information, but this Handbook should not be considered a contract, implied or

otherwise, between the YMCA and any of its associates or a guarantee of employment

for any specific period. I understand that this Handbook and the Acknowledgment Form

do not vary or modify the at-will employment relationship between the YMCA and me.

Employee Signature:


Anti-Harassment/ Anti-Discrimination Policy

I acknowledge that I have reviewed the Anti-harassment/ Anti-Discrimination policy and

understand that sexual harassment or discrimination is unlawful and that any form of

harassment or discrimination on the basis of a protected category is prohibited by the

YMCA in the workplace. I am aware of the procedures for reporting possible violations

and fully understand the consequences associated with any violation. I understand that I

am responsible for reporting a potential violation to the appropriate individual as defined

in the policy.

Employee Signature:


Employee Name (Print)

Employee ID#


Accessing the Staff Intranet:

Go to



From the Ozarks Regional YMCA main page (




Go to the “OTHER LINKS” section located on the bottom of the page and select

“STAFF INTRANET”. Then select the “HERE” link at the top of the page.

From the Employee Intranet Select the “Human Resources/Payroll” tab on the

left hand side of the page (shown below):

An “Authorization Required” pop up box will appear. Enter in the following



Username: ymcastaff


Password: 9622

You will now be able to access various HR Forms and resources, such as the

Employee Handbook, Direct Deposit Forms, links to benefits, and more!!


Rev. 03.2014

Electronic Communication


Background: The purpose of this policy is to provide guidelines for appropriate use of YMCA

electronic equipment, and appropriate electronic conduct related to communication about the YMCA.


All electronic communication systems provided by the YMCA, including but not limited to telephones, e-mail, voicemail, cell phones, Internet, and computer hardware and software, are the sole property of the YMCA. This includes all information transmitted by, received in or from, and/or stored on these systems. The use of the YMCA’s electronic communication systems is a privilege and provided only to authorized individuals.

The YMCA’s computer system and attached network may be used only for authorized official YMCA purposes. Unauthorized access to or use of the YMCA’s computer system is prohibited.

The YMCA provides Internet and email access to YMCA employees as part of their employment. The YMCA reserves the right to monitor any network user’s computer/terminal Internet and email usage. The YMCA also reserves the right to inspect any and all files stored on YMCA owned hardware or located on any YMCA premises. The YMCA has the right to monitor and record all Internet and email activities. No user should have any expectation of privacy regarding computer/terminal, Internet and/or email usage. The YMCA will assign appropriate technical staff to review Internet and email activity logs and report suspicious findings to management. The YMCA may use software to identify, monitor and restrict usage of any Internet sites it deems inappropriate. Furthermore, employees who maintain personal blogs or websites that contain postings about the YMCA’s business, programs, fellow employees, members, vendors, etc. can be held personally liable for any commentary deemed to be defamatory, obscene, proprietary or libelous.


• All YMCA issued equipment (computer hardware, cell phones, etc…) and all data generated, received or stored on such equipment are the property of the YMCA.

• NO computer communications shall contain material that could be perceived as abusive, hateful, profane, obscene, demeaning, derogatory or defamatory. This particularly includes any material pertaining to race, color, religion, national origin, gender, sexual orientation, political beliefs or disabilities or any other factor protected by law.

• ALL communications transmitted over the YMCA’s network are governed by our anti-harassment and anti-discrimination policy.

• The YMCA’s internet and email system is intended for work-related usage. Limited personal use may occur during non-work hours with prior supervisor approval.

The following are STRICTLY PROHIBITED:

• Accessing, downloading, displaying and/or distribution of sexually explicit images and materials, any materials or programs in violation of copyright protections, file sharing of films or music.

Representing or implying representation of the YMCA or their affiliates (YMCA Centers, Camps, Schools, etc.) in blogs or other personal online communications without express authorization of the Executive. The YMCA or their affiliates logo and trademarks are not to be used on personal websites or blogs. • Posting anything related to YMCA members, programs, policy, strategy, financials, products, etc.

that has not previously been made public without prior express authorization of the Center Executive and the Marketing Department.

• Engaging in online conduct or activity that may raise questions about or are contrary to the YMCA’s mission, values, character, or reputation or otherwise cause embarrassment to the YMCA.

• Emailing, instant messaging, text messaging or engaging in any other communication with youth ages 17 and under outside of normal program parameters.


Rev. 03.2014


The Ozarks Regional YMCA has the right to monitor and perform periodic inspections regarding employee email, blogging and internet use, as well as the right to retain any YMCA owned equipment at any time. Furthermore, failure by the YMCA to monitor any particular situations is not a waiver of the YMCA’s right to monitor any activities in the future.

• A password is not an indicator of personal privacy from employer monitoring.

• The YMCA will refer to this policy when questioning the proper use of YMCA computer equipment and/or blogging practices.

• If a violation of this policy is suspected to have occurred, an immediate investigation will take place to review and discover if employee misuse has occurred and appropriate corrective action, up to and including discharge will take place.

Acknowledgement and Acceptance of Policy

I, , have read the YMCA ‘Electronic Communication Policy‘. I fully understand the terms of this policy and agree to abide by its conditions. I understand the Internet is made available primarily for business purposes and agree to use it only for the acceptable purposes outlined in the policy.

I understand that the YMCA may monitor my Internet use, email use, and computer/terminal files and may record any network activity transmitted or received. These archives may be accessed by law enforcement agencies with required legal processes.

I further understand that I can be held personally liable for any commentary deemed to be defamatory, obscene, proprietary or libelous within my personal blogs or web pages that contain postings about the YMCA‘s business, programs, fellow employees, members, vendors, etc. and agree not to post any such material.

I acknowledge that violation of this policy could lead to termination, criminal prosecution, and/or civil liability.


Rev. 03.2014

Child Abuse Reporting Procedures

The YMCA advocates a positive guidance and discipline policy with an emphasis on positive

reinforcement, redirection, prevention and the development of self-discipline. At no time will the following disciplinary techniques be tolerated: physical punishment, striking, biting, kicking, squeezing, withholding food or restroom privileges, confining children in small locked rooms or verbal or

emotional abuse.

Affectionate touch and the warm feelings it brings is an important factor in helping a child grow into a loving and peaceful adult. However, YMCA staff and volunteers need to be sensitive to each person’s need for personal space (i.e., not everyone wants to be hugged). The YMCA encourages appropriate touch, however, at the same time it prohibits inappropriate touch or other means of sexually

exploiting children.

In the event that there is an accusation of child abuse, the YMCA will take prompt and immediate action as follows:

1. At the first report or probable cause to believe that child abuse has occurred, the employed staff person it has been reported to will notify his/her immediate supervisor, who will then review the incident with the YMCA executive director, or his/her designate. However, if the supervisor is not immediately available, this review by the supervisor cannot in any way deter the reporting of child abuse by the mandated reporters. Most states (including Missouri) mandate each teacher or child care provider to report information they have learned in their professional role regarding suspected child abuse. In most states, mandated reporters are granted immunity from prosecution if they make the report in good faith, which refers to the assumption that the reporter, to the best of his or her knowledge, had reason to believe that the child in question was being subjected to abuse or neglect.

2. The YMCA will make a report in accordance with relevant state or local child abuse reporting requirements and will cooperate to the extent of the law with any legal authority involved. 3. In the event the reported incidents(s) involve a program volunteer or employed staff, the

executive director will, without exception, suspend the volunteer or staff person from the YMCA pending the results of an investigation.

4. The parents or legal guardian of the child(ren) involved in the alleged incident will be promptly notified in accordance with the directions of the relevant state or local agency.

5. Whether the incident or alleged offense takes place on or off YMCA premises, it will be considered job related (because of the youth-involved nature of the YMCA).

6. Reinstatement of the program volunteer or employed staff person will occur only after all allegations have been cleared.

____________________________ _____________________


Rev. 03.2014

Code of Conduct for Staff

1. At no time during a Y program may a staff person be alone with a single child where he or she cannot be observed by others. Staff members should space position themselves in such a way that other staff can see them.

2. A child may not be left unsupervised.

3. Staff shall not abuse or mistreat children in any way, including – physical abuse—striking, spanking, shaking, slapping; – verbal abuse—humiliating, degrading, threatening;

– sexual abuse—touching or speaking inappropriately or showing children inappropriate materials; – mental abuse—shaming, withholding kindness, being cruel, belittling; and

– neglect—withholding food, water, or basic care.

4. No type of child abuse will be tolerated. Any abuse by an employee will result in disciplinary action, up to and including termination of employment.

5. Staff members may not transport children in their own vehicles.

6. Profanity, inappropriate jokes, displays of intimate affection, sharing intimate details of one’s personal life, and any kind of harassment in the presence of children, parents, volunteers, or other staff is prohibited.

7. Outside of the Y, staff members may not be alone with children whom they meet in Y programs. This includes babysitting, sleepovers, driving or riding in cars, and inviting children to their homes. 8. Staff members may not single out children for favored attention and may not give gifts to

youth or their parents.

9. Program rules and boundaries must be followed, including appropriate touch guidelines. Children may be informed, in an age-appropriate manner, of their right to set their own "touching" limits for personal safety.

10. Children may not be disciplined by use of physical punishment or by failing to provide the necessities of care.

11. Staff members may not date program participants who are under the age of 18.

12. Under no circumstances should staff members release children to anyone other than the authorized parent, guardian, or other adult authorized by the parent or guardian

(authorization on file with the Y).

13. Staff members are to make sure the rest room is not occupied by suspicious or unknown

individuals before allowing children to use the facilities. Staff members will stand in the doorway of the rest room while children are using the rest room. This policy allows privacy for the

children and protection for

the staff members (i.e., not being alone with a child). If staff members are assisting younger children, doors to the facility must remain open. No child, regardless of age, should be allowed to enter a bathroom alone on a field trip or at other off-site locations. Always send children in threes (known as the rule of three) and, whenever possible, with staff.

I understand that any violation of this Code of Conduct may result in termination.

______________________________ _____________________________ Employee Signature Date


Background Check Payroll Deduction Authorization

The Ozarks Regional YMCA takes the prevention of child abuse very seriously. Child

abuse and inappropriate contact of children is a pervasive problem throughout the

United States that must be managed in a proactive manner if we are to protect

those in our care.

To keep children in our programs safe, all employees are required to have a

background check run annually. Upon hire, the YMCA will run a National Criminal

Background check and run all employees through the Family Care Safety Registry.

On each subsequent anniversary date, employees will again be run through the

Family Care Safety Registry.

The cost of these background checks will be automatically deducted from an

employee’s first two paychecks. The Family Care Safety Registry is a one-time fee

of $12.00. The National Criminal Background check is $4.00.

Employment at the Ozarks Regional YMCA is contingent on the results of these

background checks. If either of the background checks reveal a conviction that

may present safety or security concerns or impact the individual’s ability to perform

his/her job, employment may be restricted or terminated.

By signing below, you indicate that you consent to the running of these background

checks and consent to the annual follow-up of the Family Care Safety Registry

background check. You are also consenting to the payroll deduction for these

required background checks.


Consumer Report Disclosure & Release

In connection with my employment/volunteerism or application for employment (including contract for services and volunteer work), an investigative consumer report and consumer reports, which may contain public record

information, may be requested from AMERICANCHECKED, INC. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, academic history, professional credentials, drugs/alcohol use, information relating to your character, general reputation, personal characteristics, mode of living, educational background, or any other information about you which may reflect upon your potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. Such reports may contain public record information concerning your driving record, workers’ compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records.

I authorize AMERICANCHECKED, INC. to prepare a consumer report or investigative consumer report about me and disclose such to the requesting company. Further purpose of determining my eligibility for employment

retention, promotion or suitability as a volunteer. If the requesting company is placing me with another entity, I consent to the report being provided to such other entity. If hired, contracted or accepted as a volunteer, this authorization shall remain on file and shall serve as ongoing authorization for the procurement of consumer reports at any time during my employment/volunteerism or contract period. I have been provided a copy of the summary of the rights of the consumer pursuant to the Fair Credit Reporting Act (FCRA).

I hereby fully release and discharge AMERICANCHECKED, INC., their respective affiliates, subsidiaries, directors, officers, employees, agents and attorneys thereof, and each of them, and any individual, organization, entity, agency, or other source providing information to AMERICANCHECKED, INC. from all claims and damages arising out of or relating to any investigation of my background for employment/ volunteer purposes. This release is valid for all federal, state, county and local agencies, authorities, previous employers, military services and educational institutions.

By signing below, I certify that I have read and fully understand this release, that prior to signing I was given an opportunity to ask questions and to have those questions answered to my satisfaction, and that I executed this release voluntarily and with the knowledge that the information being released could affect my being hired, my employment/volunteerism, or my eligibility for promotion.

Today’s Date________________ Signature_______________________________________________ Print your full name ______________________________________________________

For purposes of gathering this information, I agree to supply the following information, which may be required by law enforcement agencies and other entities for positive identification purposes when checking records. It is confidential and will not be used for any other purpose.

Print other last names you have used _________________________________________________ Current Address _________________________________________________ How long? ___________ City ______________________________________________ State ______________________ Zip Social Security No. _________________________________ Date of Birth ________________________ Driver’s License No. ________________________________ State Issuing License_________________

California, Minnesota and Oklahoma Applicants Only: I request a free copy of any consumer report ordered on me.


Notice To All Applicants

You have the right to receive, upon your written request within a reasonable period of time, (not to exceed 30 days) a complete and accurate disclosure of the nature and scope of the investigation requested. You have the right to make a request to AMERICANCHECKED, INC., upon proper identification, to request the nature and substance of all information in its files on you at the time of your request, including the sources of information, and the recipients of any reports on you that AMERICANCHECKED, INC. has previously furnished within the two-year period

preceding your request. AMERICANCHECKED, INC. may be contacted by mail at 4870 S. Lewis Ave., Ste. 120, Tulsa, Oklahoma, 74105, or by phone at (800) 975-9876.

Notice to California Applicants

Under California law, the consumer reports we order on you for employment purposes within the State of California are defined as investigative consumer reports. These reports may contain information on your character, general reputation, personal characteristics and mode of living. Under section 1786.22 of the California Civil Code, you may view the file maintained on you by AMERICANCHECKED, INC. during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services, by appearing at AMERICANCHECKED, INC. in person, by mail, or by telephone. AMERICANCHECKED, INC. may be contacted by mail at 4870 S. Lewis Ave., Ste. 120, Tulsa, Oklahoma, 74105, or by phone at (800) 975-9876. The agency is required to have personnel available to explain your file to you and the agency must explain to you any coded information appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes proper identification

Consumer Signature____________________________________________

Company Name: __________________________________ Location No.: ______________

Attached to this disclosure is a written summary of your rights under the Fair Credit Reporting Act (FCRA) as prepared by the Federal Trade Commission.


Rev. 03.2014

Ozarks Regional YMCA




Holiday hours worked will be paid at time and a half to employees who work on an established holiday.

All hourly employees

Jury Duty

Jury duty time off with regular pay with written notification All Regular Employees

Y Membership & Program Benefits

Free Individual Membership (Upgrade option to a Household Membership for the cost difference between the two memberships)

General Y programs, Before and After School Child Care, Day Camp & Resident Camp 50% discount

Part-Time Regular Hourly Employees

National YMCA Retirement Fund Plan

After vesting period employee will receive full contribution upon retirement.

YMCA contributes 9% of employee’s annual salary.

Part-Time Staff Who Meets the Following Eligibility Requirements Becomes Vested.

Two years of employment with the YMCA and At least 1,000 hours of employment within each year, and Attainment of age 21 by anniversary date.

403(b) Smart Account

Tax-Deferred Saving Plan. Contributions are made in pre-taxed dollars and are handled through payroll deduction.

All Regular Employees

Can participate by opening an account regardless of age, length of service, or hours worked



Welcome to the YMCA! A benefit of your employment is a Y membership. Please complete the employee

section of this form and present it to the Membership Desk of the YMCA Center of your choice. You will

be asked to complete a Membership Application form and additional forms if needed.


(please print)

Do you currently have a YMCA Membership?





If yes, please specify membership Type:





Employee receives free Individual Membership. Upgrade to a Household is optional.


Please change my current Individual membership plan to Household Upgrade. (Fees shown below)

If you do not have a current membership, please specify type of membership desired




Household Employee Upgrade (Part-Time employee upgrades for the diffrence between the Household

and Individual Membership)


Household employee (Full-Time employee)

If at any time you change your membership type, you must notify the Membership Department in

writing 10 days advanced of your EFT (Electronic Funds Transfer) draft date.

Begin date of employment____________________________________________________________________________________________



Please check employment status:

Regular PT Hourly


Temporary PT




Regular FT Hourly


Temporary FT


Supervisor’s Signature:

____________________________________________________________________________________________ Date ___________________________

To be completed by Membership or Reception Desk Staff:

Date received at Membership Desk__________________________________________________________________________________

Staff signature___________________________________________________________________________________________________________



Wednesday, January 1 (New Years Day)

Monday, May 26 (Memorial Day)

Friday, July 4 (Independence Day) Monday,

September 1 (Labor Day)

Thursday, November 27 (Thanksgiving Day)

Thursday, December 25 (Christmas Day)

Holiday hours worked will be paid at time and a half to the following employees who

work on Association-established holidays:


All regular part-time and full time hourly employees


All temporary hourly employees


Payroll Calendar - 2014


Period Covered


12/21/13 through 1/5/14


1/6/14 through 1/20/14


1/21/14 through 2/5/14


2/6/14 through 2/20/14


2/21/14 through 3/5/14


3/6/14 through 3/20/14


3/21/14 through 4/5/14


4/6/14 through 4/20/14


4/21/14 through 5/5/14


5/6/14 through 5/20/14


5/21/14 through 6/5/14


6/6/14 through 6/20/14


6/21/14 through 7/5/14


7/6/14 through 7/20/14


7/21/14 through 8/5/14


8/6/14 through 8/20/14


8/21/14 through 9/5/14


9/6/14 through 9/20/14


9/21/14 through 10/5/14


10/6/14 through 10/20/14


10/21/14 through 11/5/14


11/6/14 through 11/20/14


11/21/14 through 12/5/14


12/6/14 through 12/20/14


Access to Online Paystubs

The Ozarks Regional YMCA will automatically post your paystubs to our own secure

portal as part of the payroll process. You will not receive paystubs in the mail. In

addition to viewing your paystubs, you can also view your tax information, mailing

address on file with payroll, and copies of your W2.

You can access the “MyPy” Online Paystub site at:


OR a link is provided on the Staff Intranet under the “Human

Resources/Payroll” tab

To Login:

Payroll ID: This is also your Employee ID – which you use to clock in and out. If

you happen to clock in and out with your last name, you can find your Payroll

ID/Employee ID number next to your name when you are clocking in and out.

Password: Your assigned password is “ymca$”, followed by the last 2 digits of

your social security number. For example: if the last 2 digits of your social

security number is “45”, your password would be “ymca$45”. You can always

change your password once you are logged into your account.


Page 1 of 2

Whatever your age, length of YMCA service, hours worked, or eligibility in the Retirement Plan, you may open a 403(b) Smart Account at any time during your YMCA employment.

Why Should I Save?

Financial planners recommend that you save at least 15% of your salary toward retirement each year throughout your ca-reer in order to retire comfortably. If you participate in the Retirement Plan, you’re partway there. Saving in a 403(b) Smart Account will make up the rest. It will also allow you to:

• Defer Your Taxes

By saving in this account, you reduce your taxable income. You pay Social Security and Medicare taxes on the amounts you save, but you will not pay federal income taxes on those amounts, or on their earnings, until you retire or withdraw them.

• Borrow from Yourself, and Pay Yourself Back

While you are working for the Y, you can borrow from your accounts in the Savings Plan (403(b) Smart Account and Rollover Account). For more information, visit our website, www.yretirement.org.

• Be Flexible

You can adjust your contribution amount at any time—start saving now and increase when possible. If you choose a different career path, you can transfer your account to a new qualified retirement plan.

8 0 0 - R E T - Y M C A ( 7 3 8 - 9 6 2 2 ) • i n f o @ y m c a r e t . o r g • w w w . y r e t i r e m e n t . o r g

© 2013 YMCA Retirement Fund. All Rights Reserved. If any inconsistencies arise between this document and the Retirement Fund Plan Documents, the language in the official Plan Documents will govern.



Total Contributions 100% of your compensation* or $52,000 (whichever is less)

Age 50+ Catch-Up $5,500

*Th e IRS Code limits includable compensation to $260,000



Tax-Deferred Contributions Maximum

(individual limit from all salary reduction retirement plans) $17,500

15+ Years of Service Catch-Up *

(increases tax-deferred contribution maximum) $3,000

Age 50+ Catch-Up

(increases both total and tax-deferred contribution maximum) $5,500

* Th e 15+ Years of Service Catch-Up amount is based on years of YMCA service and can be as much as $3,000 but is limited based on how much you’ve contributed in the past. Call Customer Service at 1-800-RET-YMCA for more info about your eligibility.


Open a 403(b) Smart Account today!

How Much Can I Save?

Federal law puts limits on the total amount that can be contributed to your retirement savings each year. In 2014, you can save 100% of your compensation, or $52,000, whichever is less. If you turn age 50 or older you may “catch-up” by saving an additional $5,500 tax deferred.



SMART 11/13

Salary Reduction Agreement

Employee Authorization

Male Female Single Married Divorced Widowed

_____________________________________________________________________________________________ ______/ _____/______ First Name Middle Last Name Date of Birth (mm/dd/yyyy)

Street Address City State Zip

Home Phone Email Name of your YMCA

__________________________________________________________ ______/______/______



Job Title Date of Hire (mm/dd/yyyy) Social Security Number

I authorize (choose one): a contribution of _________ % of my salary, per pay period to begin on _____/_____/_____ (mm/dd/yyyy)

a contribution of $ __________________ per pay period to begin on _____/_____/_____ (mm/dd/yyyy)

a one-time contribution of $ _______________ from my paycheck on _____/_____/_____ (mm/dd/yyyy)

I understand that these funds are for use as an annuity at retirement or a distribution upon termination of employment in accordance with the terms of the Plan. In the event of my death prior to retirement or termination, my account balance will be paid to my named beneficiary(ies). By signing here, I agree to the Salary Reduction Agreement detailed below. I understand that if I am not yet a participant in the Retirement Plan, once I become enrolled in the Retirement Plan and the YMCA starts making contributions on my behalf, this may reduce the amount I am eligible to contribute to my 403(b) Smart Account.

EMPLOYEE SIGNS _________________________________________________________________________ _____/_____/_____

Date (mm/dd/yyyy)

Please tell us how you learned about the advantages of a 403(b) Smart Account: Email from the Fund Fund Website Fund Facebook Page Fund Presentation

Benefits Statement YMCA HR Department/Leadership Staff at the Y Fund Customer Service Representative Other

YMCA Authorization

(Name of YMCA) __________________________________________ (YMCA #) ____________ agrees to the terms of the Salary Reduction Agreement below and will send the YMCA Retirement Fund the stated employee’s contribution for his/her 403(b) Smart Account.

LOCAL PLAN ADMINISTRATOR SIGNS _____________________________________________________ _____/_____/_____

Date (mm/dd/yyyy)

Keep this completed form on record at your YMCA and do not send it to the Fund. Use YERDI to open, adjust or end 403(b) Smart Account contributions.


Once you complete this form, please return it to your YMCA’s Human Resources Department.

Page 2 of 2 This salary reduction agreement enables a YMCA employee

to make pre-tax contributions (excluding Social Security and Medicare taxes) to the YMCA Retirement Fund Tax-Deferred Sav-ings Plan (“SavSav-ings Plan”) to be allocated to his or her SavSav-ings Plan account (“Account”).

We, (participating YMCA and employee), agree that the employ-ee’s compensation (as defi ned in the Savings Plan) will be re-duced as stated on this form. The voluntary contributions will be contributed to the employee’s Account in the Savings Plan. Sal-ary reductions apply only to compensation earned after com-pleting this agreement and cannot be retroactive. Employees are always vested in their Account.

Contributions made under this agreement are not subject to federal income tax and may not exceed federal contribution lim-its. Any contributions over the limit will be returned to the em-ployee and will be part of taxable compensation. Contributions are not reported as a part of “wages, tips, other compensation”

subject to federal income tax on the participant’s IRS Form W-2 (however, they will be reported elsewhere on the form). Contri-butions are subject to Social Security taxes, and may be subject to state income tax. Responsibility for withholding and reporting any state income tax rests with the YMCA.

Changes in contributions of a set dollar amount each payroll period will require that a new form be completed by both the YMCA and the employee. If the contributions are based on a percentage of compensation, there is no need to fi ll out a new form for compensation changes, unless the participant so chooses.

The IRS permits pre-tax saving as a method of building sav-ings for retirement. There are no withdrawals while working for the YMCA except in the case of personal hardship as provided under federal law. Hardship withdrawals are subject to regular income tax and an early withdrawal penalty tax if the employee is not 59½.

If the participating employee leaves the YMCA, they may leave their Account in the Savings Plan to grow with interest until they begin retirement benefi ts. Inactive participants with Account balances of $5,000 or less may be subject to an immediate distribution or mandatory rollover as provided under Savings Plan terms and as permitted by federal law. If they withdraw their tax-deferred money, they may roll it over to another eligible employer plan or IRA without tax consequences. However, if they do not roll it over, it is subject to regular income tax and usually an early withdrawal penalty tax if they are not 59½.

This agreement shall continue indefi nitely unless the employee chooses to terminate it. It can be revoked by the employee at any time, although contributions will stop at the end of the pay-roll cycle. Termination of employment terminates this agreement and re-employment requires re-application to open an Account. This agreement is not an employment contract, and creates no rights to continued employment by the YMCA.



Name___________________________________________________________________________ Date ___ /___ /___ Address___________________________________________________________________________________________ City _____________________________________________________ State ________ Zip______________________ Work ph ___________________________________________________________________________________________ Home ph ___________________________________________________________________________________________ Email _______________________________________________________________________________________________

How would you like your name to appear in our recognition materials?


Please return completed form to Rhoda Clark at Ozarks Regional YMCA,

For more info call 417.862.8962 X 159

TOTAL GIFT $ _________________________________________________________

I would like my gift to remain anonymous


Please choose one of the following. Enclosed is my check for $_________________

Please deduct $ __________________ per pay check Please deduct $ __________________ one time


please send reminder and I will send a check



*Minimun for payroll deduct is $10 (total) gift

Please return completed form to Nancy Berlin at Ozarks Regional YMCA,

417 S. Jefferson, Springfield, MO 65806, For more info call 417.862.8962 x 2114

CENTER LOCATION _________________________________________________




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