Employment Application

EMPLOYEE APPLICATION
Application Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Address
Phone
Are you of the age 18 or older?

YesNo
U.S. Citizen?

YesNo
Social Security Number
In case of emergency, contact:
Relationship
Phone
Are you under a doctor's care?

YesNo
If yes, please explain
Are you able to lift up to 25 pounds?

YesNo
If no, please explain.
Do you have any disabilities? If yes, please explain

YesNo
If yes, explain
Have you ever been convicted of a crime?

YesNo
If yes, please explain.
Are you presently employed?

YesNo
Position applying for:
Preferred Age Group
Group Care Experience
Will you have a child attending The Way PDO?

YesNo
Educational Background
High School
Received Diploma or Equivalent?

YesNo
College
Received Diploma or Equivalent?

YesNo
Major
Postgraduate College
Received Diploma or Equivalent?

YesNo
Major
EMPLOYMENT HISTORY Please list previous employment, starting with most recent (You may attach a resume with additional information)
May we contact the individuals below for references to your work?

YesNo
If no, please explain.
Place of Employment
Position
Duties
Start Date

MonthDayYear
Date
Ending Date

MonthDayYear
Date
Reason for Leaving
Ending Salary
Supervisor
Phone Number
Place of Employment
Position
Duties
Start Date

MonthDayYear
Date
Ending Date

MonthDayYear
Date
Reason for Leaving
Ending Salary
Supervisor
Phone Number
Place of Employment
Position
Duties
Start Date

MonthDayYear
Date
Ending Date

MonthDayYear
Date
Reason for Leaving
Ending Salary
Supervisor
Phone Number
By completing this application, you give permission for the child care director to contact your references, verify your past work history, conduct a criminal background check, verify your driving record, and contact your previous employers to determine your suitability in working in the child care center. By signing this application, you affirm that the information is true to the best of your knowledge. You also agree to release the center for any liabilities that result from the verification. Thank you.
Signature

Clear
Date

MonthDayYear
Date
Please list 3 personal references (not related) - Name, Address, Phone Number
1.
2.
3.
Do you have any special skills or talents that would be beneficial in working with young children? (Please include administrative, organizational and communication skills.)
What 3 words describe your personality? (Describe their importance in a childcare ministry/program)
1.
2.
3.
Describe the role that parents, children and teachers play in a child care program.
Parents
Children
Teacher
What do you think makes a successful childcare program?
What behavior do toddlers and pre-school age children exhibit when they are bored?
As a teacher, what steps would you take to inform a parent of an accident? Confront a parent of a disruptive child? Respond to a voiced concern?
Should be Empty:

EMPLOYEE APPLICATION

Educational Background