Position Applied for:
Name
*
First Name
Last Name
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Phone
*
(###)
###
####
Birthdate
*
MM
DD
YYYY
Social Security Number
Educational Experience
*
Please list degrees (from most current to high school).
Experience with Groups of Children
*
Please include ages of children, responsibilities, span of time you held these positions, and reason for leaving.
Have you completed any child care training courses?
If yes, then please list the courses:
Work History
*
Please list ten-year employment history below. Begin with the most current. Including the following: Dates (first to last), Name and Address of Employer, Position. If you were unemployed, please describe how you spent your time.
Attach documentation of experience with working with children.
May we contact previous employers?
Yes
No
Do you have a criminal record?
*
Yes
No
If yes, explain.
Have you ever been shown by credible evidence (for example, a court order or jury, a department investigation or other reliable evidence to have abused, neglected, or deprived a child or adult or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct)?
*
Yes
No
If yes, explain:
If no, please explain.
Do you have a valid driver's license?
Yes
No
If yes, driver's license number:
If yes, driver's license class:
Have you had CPR training within the past two years?
*
Yes
No
If yes, expiration date:
MM
DD
YYYY
What is your COVID vaccination status?
*
Not vaccinated
One shot of Pfizer or Moderna
One shot of Johnson & Johnson
Two shots of Pfizer or Moderna
One shot of Johnson & Johnson + a booster shot
Two shots of Pfizer or Moderna + a booster shot
I certify that all information on this application is correct. I have not given any false statement concerning my qualifications requirements.
*
Signature
First Name
Last Name
Date signed
*
MM
DD
YYYY
