BYA New Employee Form
Center
(Required)
MT - 4107
NB - 4106
OS - 4418
WH - 4642
NT - 4722
NM - 30038
MB - 30316
SB - 30329
GF - 30445
KW - 30589
Please Select One
Employee Information
Employee's Name
(Required)
First
Last
Employee's Personal Email Address
(Required)
Employee's Phone
(Required)
Employment
(Required)
Full Time
Part Time
Employee's SSN
(Required)
Employee's Date of Birth
(Required)
MM slash DD slash YYYY
Start Date
(Required)
MM slash DD slash YYYY
Employee's Home Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Acknowledgements
I understand and accept that I will only be paid for the hours agreed upon as per my direct report. Additional hours must be approved. I accept that my schedule may be changed to accommodate the needs of the center such as leaving early as per ratio leave. I understand this will not affect my full time status or result in reduced benefits.
I authorize that:
(Required)
Un-returned key fobs at the end of employment will result in a $5.00 deduction
Un-returned BYA logowear will result in a $18.00 per item deduction
Un-attended Prof. Development will result in a deduction equal to the fee BYA incurred
Select All
Please agree to all three
Department
(Required)
100 - Corporate
200 - Manager
300 - Teacher
400 - Consultant
500 - Maintenance
600 - 1099
Pay Type
Salary
Hourly
Salary (Per Year)
Hourly Rate (Per Hour)
Child Care Services
Will you be enrolling a child?
(Required)
Yes
No
Bi-Weekly Deduction
Child Care Services Start Date
MM slash DD slash YYYY
NOTE: All paycheck deductions are for services that occurred in the paycheck’s coordinating payroll period.
Federal and State Tax Info
Federal Filing Status
(Required)
Single (or Married filing seperately)
Married (or Married filing jointly)
Head of Household
Federal Claim Dependents #
or Dependent Allowance Amount
Extra Federal Witholding Amount
State Filing Status
A
B
C
D
E (Exempt)
F
A, B, C, D, E (Exempt), or F
Extra State Witholding Amount
Benefits Election Response
MANDATORY FOR ALL EMPLOYEES
Medical Coverage
Accept
Decline
I decline medical coverage due to:
Spousal Coverage
Other Coverage
No Coverage
Select One
If my response changes I will submit the Employee Enrollment Application to the business office by the 15th of the month prior to the eligibility date. The eligibility date is the 1st of the month after 60 days of hire.
Traveling to other BYA Locations
Willing to travel
(Required)
Yes
No
I am willing to travel to other BYA locations if needed
Employee Signature
Form Completion Date
(Required)
MM slash DD slash YYYY
Signature
