Employment Application

Employment Application
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Birth Date*

MonthDayYear
If you are under 18 can you submit a work permit if hired:
If you are not a US Citizen, do you have a VISA to work in the US?*
Employment Desired*
Days Available:

MondayTuesdayWednesdayThursdayFriday
Hourly Rate Desired:
Education
High School
Date Graduated

MonthDayYear
Date
College Attended
Date Graduated

MonthDayYear
Other Certifications
Personal References (do not list family)
1st Reference Name*

First NameLast Name
1st Reference Relationship*
1st Reference Phone Number*
Please enter a valid phone number.
2nd Reference Name*

First NameLast Name
2nd Reference Relationship*
2nd Reference Phone Number*
Please enter a valid phone number.
3rd Reference Name*

First NameLast Name
3rd Reference Relationship*
3rd Reference Phone Number*
Please enter a valid phone number.
Employment History

Please list all employment history for the last 10 years. Beginning with your most recent employer. LEAVE NO GAPS. If you were not employed please list how you spent your time ie student, stay at home mom, unemployed etc.
Name of most recent Employer
Address of most recent employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date Most Recent Employer

MonthDayYear
End Date Most Recent Employer

MonthDayYear
Position Held Most recent employer
2. Employer
2. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Start Date

MonthDayYear
2. End Date

MonthDayYear
2. Position Held
3. Employer
3. Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Start Date

MonthDayYear
3. End Date

MonthDayYear
3. Position Held
4. Employer
4. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
4. Start Date

MonthDayYear
4. End Date

MonthDayYear
4. Position Held
5. Employer
5. Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5. Start Date

MonthDayYear
5. End Date

MonthDayYear
5. Position Held
Additional Questions
Do you have a criminal background?
if Yes, Please explain:
Have you ever been shown by credible evidence, e.g. a court order or jury, a department’s investigation or other reliable evidence to have abused, neglected or deprived a child or adult of to have subjected any person to serious injury of intentional or grossly negligent misconduct?
if Yes, please explain:
Under the American with Disabilities Act of 1991, this program is required to reasonably accommodate individuals with a disability. The reasonable accommodation requirement applies to the application process, any pre-employment testing, interviews, and actual employment, but only if the program supervisor is made aware that an accommodation is required. If you are disabled and require accommodation, you may request it at any time during the interview process. You are obligated to inform the program director of your needs if it will impact your ability to perform the job for which you are applying.
Would you be able to lift up to 35 lbs on a regular basis, sit on the floor with children, repetitive bending and perform general cleaning duties?
Having read the job description for the position desired, are you in all respects, able to adequately perform the duties described?
Do you have a valid Driver's License?
Have you had CPR Training in the last two years?
Date of CPR Training

MonthDayYear
Bright from the Start of Georgia Department of Early Care and Learning requires annual childcare training. Are you willing to participate?
Please answer the following questions to the best of your ability
1. Parent communication is vital when working in a childcare setting so that parents feel comfortable and connected to what is going on. How might you help parents to feel welcome and comfortable dropping their child off for the first time?
2. Iva is 2 months old and is exhibiting some unusual “fussy” behavior. She is refusing to take her bottle and it is time for two other babies to eat and they are starting to get upset. How might you handle this?
3. In your classroom of two-year olds, John is having difficulty with biting. While you are changing a diaper, you notice John playing with Ellie in blocks. John takes a block from Ellie and then proceeds to bite her on the arm. What steps should be taken during this situation and how might you prevent this from occurring in the future? What might you say to both parents at pick-up time?
4. You are in a classroom with school-agers. The classroom has been asked to clean up from an activity and Braylon is refusing to do so. He becomes upset and starts to scream NO and picks up a book and throws it. The book hits another child. What steps are necessary in this situation?
5. In a potty training classroom, a parent is extremely insistent that Brynlee be potty trained. Brynlee is a child that has difficulty with transitions and change. During potty time Brynlee refuses to cooperate and becomes upset. What are strategies that could be taken to help Brynlee?
6. Being a team player when working in a childcare environment is vital for accomplishing our goal as a school. What does your outlook on being an effective team player look like (remaining positive, gossiping, etc.)
7. What is your philosophy of education and what does being a successful teacher look like to you?
I certify that all information on this application is correct. I have not given any false statements concerning my qualification requirements.
Signature

Clear
Today's Date

MonthDayYear
Should be Empty:

Employment Application

Education

Personal References (do not list family)

Employment History

Additional Questions

Please answer the following questions to the best of your ability