Job Application

Personal Information
Your Name*

First NameMiddle NameLast Name
Best Way to Reach You*

CellHome NumberWork NumberEmailOther
Contact Email Address

Confirmation Emailexample@example.com
Cell Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number

Area CodePhone Number

Educational History & Licenses
High School
College
Graduate School
Do you hold any professional licenses, certificates, endorsements or permits?
Please list any honors, commendations, elective or appointive offices held, or other distinctions received.
Are you legally eligible to work in the United States? Please note that Cajal Academy is not in a position to sponsor foreign work visas at this time.*

YesNo

Legal Disclosures & Consents

The state of Connecticut requires that we obtain the following information, consents and releases from any and all applicants for positions that will involve contact with our students.
Prior Work Experience With Children

Connecticut state law requires that you provide information regarding any and all prior employment (including volunteer, independent contractor and employee relationships) meeting the criteria listed below, and that you provide your consent for any such employers to disclose certain information to Cajal Academy, Inc. before you can be considered you for any position in which you would have contact with our students.
Please provide the following information for all prior employment experiences with a local or regional board of education/council. If you have not add any such employment, please type "None." Please use the "+" sign to add a new row for each relevant employment experience:*
Please provide the following information for all prior employment experiences at a public, private or parochial school. Please use the "+" sign to add a new row for each relevant employment experience:*
Please provide the following information for any other prior employment experiences not listed above that involved contact with children. Please use the "+" sign to add a new row for each relevant employment experience:*
Consent and Release for Disclosure of Information by Prior Employers

1. I hereby consent to, authorize and instruct each of the above listed entities to disclose to Cajal Academy, Inc. the following information and any records related thereto:

(a) the dates of my employment with said entity,

(b) whether the employer has knowledge that I was the subject of an allegation of abuse or neglect or sexual misconduct for which there is an investigation pending with any employer, state agency or municipal police department or which has been substantiated,

(c) whether I was disciplined or asked to resign from employment or resigned from or otherwise separated from any employment while an allegation of abuse or neglect or sexual misconduct was pending or under investigation, or due to a substantiation of abuse or neglect or sexual misconduct, and

(d) whether I have ever had a professional or occupational license, certificate, authorization or permit suspended or revoked or have ever surrendered such a license, certificate, authorization or permit while an allegation of abuse or neglect or sexual misconduct was pending or under investigation, or due to a substantiation of abuse or neglect or sexual misconduct.

2. I hereby release any and all prior entities and employers from any and all liability that may arise from such disclosure or release of records.
Signed:

Clear
Department of Education Review -- Required for all applicants

Connecticut state law also requires Cajal Academy to request from the Department of Education any information they may have that is relevant to determining your eligibility for employment in a position requiring contact with students. This applies to all applicants, regardless of whether you have previously been employed in a position in which you had contact with children.
Consent and Release for disclosure of information by state Department of Education:

Under Connecticut state law, you must provide your consent to the following disclosure of information by the Department of Education in order for Cajal Academy, Inc. to consider you for any position (whether as a paid employee, independent contractor or volunteer) in which you will have contact with students:

1. I hereby consent to, authorize and instruct the Department of Education to disclose to Cajal Academy, Inc. the following information and any records related thereto:

(a) my eligibility for employment in a position that, if in a public school, would require a certificate, authorization or permit (i.e., teacher, supervisor or administrator certifications)

(b) whether the department has knowledge that a finding has been substantiated by the Department of Children and Families pursuant to section 17a-101g of abuse or neglect or of sexual misconduct against me and if so, any information concerning such a finding, and

(c) whether the department has received notification (i) that I have been convicted of a crime or (ii) of criminal charges pending against me and any information concerning such charges.

2. I hereby release the Department of Education from any and all liability that may arise from such disclosure or release of records.
Signed:*

Clear
Background Information

Connecticut state law requires that we ask the following information of all applicants who will have contact with children in the course of their job responsibilities.
Have you ever been the subject of an abuse or neglect or sexual misconduct investigation by any employer, state agency or municipal police department, other than an investigation that resulted in a finding that all allegations against you were unsubstantiated?*

YesNo
Have you ever been disciplined or asked to resign from employment (or resigned from or otherwise separated from anyemployment) while (i) an allegation of abuse or neglect was pending or under investigation by the Department of Children and Families, (ii) an allegation of sexual misconduct was pending or under investigation or (iii) due to an allegation substantiated pursuant to section 17a-101g of abuse or neglect, or of sexual misconduct or a conviction for abuse or neglect or sexual misconduct?*

YesNo
Have you ever had a professional or occupational license or certificate suspended or revoked, or surrendered such a license or certificate, (i) while an allegation of abuse or neglect was pending or under investigation by the Department of Children and Families or (ii) while an investigation of sexual misconduct was pending or under investigation, or (iii) due to an allegation substantiated by the department of abuse or neglect or of sexual misconduct or a conviction for abuse or neglect or sexual misconduct?*

YesNo
Are you aware of any reason why you may be disqualified from working in a position that will bring you into contact with children?*

YesNo

References
Please provide contact information for at least four individuals who are very familiar with your professional work and character, and whom we may contact for a professional reference. We typically do not contact references prior to interviewing candidates, and we will let you know before we reach out to any of your references. You may add additional references by pressing the '+' symbol below.*
I hereby give my consent to Cajal Academy to contact the above-listed references on my behalf. I also provide my consent for the above-listed entities or individuals to disclose information to Cajal Academy regarding my professional work, character, prior employment history and such other information as may be deemed relevant to my consideration for employment or volunteer positions with Cajal Academy.*

Clear

Equal Opportunity Employer
If hired, I agree to abide by this policy and do my best to further the principles behind it.*

Clear
Cajal Academy is an Equal Opportunity Employer and Prohibits Discrimination and/or Harassment of Any Kind:

Innovating education requires that we engage and retain the very highest possible caliber of staff. Discrimination, harassment or creating a hostile environment of any kind undermines our ability to attract and retain such staff members and will not be tolerated.

Cajal Academy is committed to the principle of equal employment opportunity for all employees and to providing employees with a work environment free of discrimination and harassment. All employment decisions at Cajal Academy are based on business needs, job requirements and individual qualifications, without regard to race, color, religion or belief, gender, gender identity, sexual orientation, age, family or parental status, or any other status protected by the laws or regulations applicable in the state of Connecticut. Cajal Academy will not tolerate discrimination or harassment based on any of these characteristics. Cajal Academy encourages applicants of all backgrounds and ages.

Agreement

Please read the following statements carefully and then acknowledge your agreement by electronically signing below.
By my signature:

• I acknowledge that individuals who provide false, inaccurate, or incomplete information in the application form, in an interview, or any other part of the hiring process or who fail to disclose information requested in the application form, in an interview, or any other part of the hiring process will not be eligible for employment, or, if they are hired, they will be subject to termination.

• I acknowledge that to the fullest extent permitted by state and federal law, Cajal Academy will consider all information concerning an applicant or an employee in making hiring, termination, and other employment-related decisions. The term "all information" includes information of any kind (verbal, written, photographic, videographic, etc.) that is accessible in any medium (print, electronic, etc.) from any source.

• I acknowledge that Cajal Academy may consider public information and other information to which it has lawful access. This may include information that is contained in social networking sites, blogs, and other electronic sites, such as YouTube. If there is information that pertains to me that I believe requires explanation, interpretation, or clarification when it is considered by Cajal Academy, it is my obligation to communicate this information to Cajal Academy.

• I authorize Cajal Academy to conduct a complete check regarding my background including, but not limited to, criminal record, child and dependent adult abuse registry screening, and sex offender registry. I agree to prepare and sign any other form necessary to complete a criminal background check. I further authorize all government agencies departments, bureaus, or related entities to release any and all information regarding my criminal history, if any. I agree to immediately notify Cajal Academy if I should be convicted of any crime while my application is pending, or during my period of employment, if hired.

• I authorize all current and former employers, teachers, and references to release all information regarding my professional competence, performance, character, and background. I waive any right I may have against any person contacted as a reference concerning this application.

• I acknowledge that information that is relevant to Cajal Academy's decisions will be considered regardless of the date on which Cajal Academy obtains the information and regardless of the date on which the information was first published, created, or made accessible to the District.

• I understand that this application will be considered active for twelve (12) months from the date filed. I further understand that if I am employed by Cajal Academy, this application and associated documents will become part of my permanent record.

• I understand that this application is not a contract of employment and does not create an employment relationship between myself and Cajal Academy. In accepting the position, if hired, I understand that employment is at will, unless otherwise specified by a written agreement executed between myself and Cajal Academy. I acknowledge that Cajal Academy may discharge an at-will employee at any time for any legal reason or no reason at all.

• I agree to submit to both pre-employment and post-employment random drug and alcohol testing as and to the extent described in the Cajal Academy Staff Handbook.
By my electronic submission of this form:

• I attest that all the information contained in this application is accurate, complete, and true.

• I am bound by all elements of the agreement section of the application.

• I understand and accept that electronic submission will be considered equivalent to an original hand written signature on a paper copy of the application.
Name*
Signature*

Clear
Date*
Should be Empty:

	As an Employee	As (or for) an Independent Contractor	As a Volunteer	Not in any capacity
With a local or regional board of education or council
With a school (including public, private, parochial and other schools, regardless of the children's ages)
In a day care center or other facility having responsibility for young children
In a therapeutic setting such as a clinic, hospital or private practice
In any other job that involved contact with children

	# years	Role	Certifications (if relevant)
Kindergarten-grade 2
Grades 3-5
Grades 6-8
Grades 9-12

Personal Information

Employment Application

Educational History & Licenses

Professional Experience

Legal Disclosures & Consents

Prior Work Experience With Children

Department of Education Review -- Required for all applicants

Background Information

References

Equal Opportunity Employer

Agreement