application

Application for Employment with Lakeside Weekday Education Program
Name

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social Security number
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Church Membership
In case of Emergency, who should we notify?
Emergency Contact Phone Number
Format: (000) 000-0000.
Position Applying for
Date Available to Start

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Why do you want to work here?
Education Experience: Please list schools attended, dates, and majors
Please list any courses, volunteer work, hobbies or interests that would relate to the position you are applying for
Please list any community organizations you are active in
Former Employers
Name
Dates Employed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
Phone
Format: (000) 000-0000.
Salary on leaving
Position
Supervisor's Name
Duties
Reason for leaving
Name
Dates Employed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
Phone
Format: (000) 000-0000.
Salary on leaving
Position
Supervisor's Name
Duties
Reason for leaving
Name
Dates Employed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
Phone
Format: (000) 000-0000.
Salary on leaving
Position
Supervisor's Name
Duties
Reason for Leaving
References: Please list at least three persons, not related to you, whom you have known at least one year who could attest to your interaction with children. The phone number should be active during the work day.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
How would you describe your general health?
Are there any physical or personal limitations on the type of work you can do with children at the church, or that would affect the amount of time you can spend at work?
If yes, please explain
Date of your last physical exam

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you object to being fingerprinted?
Have you ever been convicted of a felony?
Do you have a Driver's license?
Have you ever been convicted of child abuse?
What is your philosophy of early childhood education?
What is your philosophy of behavior guidance?
If hired, what kind of commitment do you expect to be able to give to our program?
What would you say are your goals for the next I to 5 years?
If we were to ask your best friend what he/she thought your 5 best qualities are, what do you think he/she would say?
If we asked that same person what areas you needed to improve upon, what would he/she say?
What age group do you prefer working with?
Is there an age group you absolutely would not want to work with?
Which positions are you interested in?
In compliance with the requirements of this child care program, no person shall be hired or retained as a staff member, paid or volunteer, who has:

a) been convicted of, admitted to, or been the subject of substantial evidence of an act of child abuse or child molestation

b) used alcohol or drugs such that its effects are apparent during working hours that children are in care

c) been convicted of or admitted to any felony or any offense involving moral turpitude.

I am aware that a background study will be performed before I can be hired. I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts called for is cause for dismissal.

In the event of my employment, I agree to comply with the rules and regulations governing my employment. In the event I should terminate my employment, I agree to file my resignation two weeks prior to the date it will be effective.

I understand that the first three months of my employment are probationary and that if my services have not proved satisfactory during that time, my employment may be discontinued at any time.
Applicant's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Former Employers