Internship/Practicum Application

Internship/Practicum Application
We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, genetic information, marital or veteran status, or any other legally protected status. Federal law requires us to provide reasonable accommodation for known disabilities, unless to do so would pose an undue hardship. Please let us know if you need an accommodation to complete the application process.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Please note: We are smoke and tobacco-free on all premises operated by the Crisis Nursery. The Crisis Nursery requests that All Students Are Expected To Remove Piercing (Except Ear Lobes) and May Be Asked To Cover Body Art While At The Nursery or Representing The Nursery, If Found Inappropriate For Children. Minimum of One-Year caring for children is required for all positions unless otherwise stated.
Name*

First NameLast Name
Email*
example@example.com
Maiden Name (If applicable)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Name of College/University
Degree

AssociatesBachelorsMasters
Field of Study
Total Hours Needed
Desired Start Month/Year
Anticipated Completion Date
University Contact- Name/Department*
University Contact- Email/Phone Number*
List Days & Times Available to Complete Hours
Languages Spoken other than English*
Level of Fluency

NoviceIntermediateAdvancedSuperiorDistinguished
Choose the Best Location(s) for You*

St Louis CitySt Louis South CountySt Louis North CountySt Charles CityWentzville
How Did You Hear About the Crisis Nursery?
Please List All State You Have Worked In, Lived In, or Attended School In Within the Last 5 Years
Do You Have a Social Security Card?

YesNo
APPLICANT’S STATEMENT: PLEASE READ THIS STATEMENT CAREFULLY, SIGN AND DATE BELOW. YOUR APPLICATION WILL BE CONSIDERED INCOMPLETE IF NOT SIGNED AND DATED.

This document serves solely as a clear and conspicuous written disclosure as required by the Federal Fair Credit Reporting Act set forth in Section 604(b) to the Applicant that previous employment, education, social security, credit, motor vehicle report, and a criminal background check may be obtained for the purpose of this employment application only. Your signature below acknowledges that the Saint Louis Crisis Nursery has made this disclosure. I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application, as well as information concerning me from my present (unless otherwise indicated by me) and former employers as may be necessary in arriving at an employment decision. I authorize my employer or potential employer to investigate, obtain, compile, examine, copy, or receive any records pertaining to my employment history and completely and without reservation allow my employer to release and/or discuss any information about my employment history with authorized personnel of the Department of Social Services. I further authorize the Department of Social Services to share any personnel information that the Department of Social Services may have about me with my employer or prospective employers as the Department determines necessary to make personnel decisions regarding my suitability to provide services with my employer. By authorization of the above, I agree to hold harmless any individual, partnership, corporation, educational institution, or agency, The Department of Social Services, the Missouri Children’s Division, it’s officers, agents and employees, as well as the State of Missouri, from any liability for any damage whatsoever for issuing such information. This application contains no misrepresentation or falsifications and the information given is true and complete to the best of my knowledge and belief. I am aware that, should an investigation at any time disclose any such misrepresentation or falsification as to a material fact, the application will be rejected or, if selected, I may be dismissed by the employer/contractor.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

Clear
By Checking This Box I Certify That I Have Signed This Application

Yes
Please Review and Initial Indicating Your Understand and Agreement
Initial   The St. Louis Crisis Nursery Is a Smoke and Tobacco Free Environment

Initial   All Students Are Expected To Remove Piercing (Except Ear Lobes) and May Be Asked To Cover Body Art While At The Nursery or Representing The Nursery, If Found Inappropriate For Children

Initial   All Practicum Placements Are Conditional On The Acceptable Results of Background Screenings Which Include the Family Care Safety Registry and Fingerprinting That Is Run Nationwide Through the FBI and must exclude certain offenses due to state requirements

Please consider whether it is in your best interest to pursue a practicum with the Nursery, as fingerprinting is at the cost of the student and the Crisis Nursery is unable to refund fees if placement is not approved.
Please Upload Resume & Cover Letter*

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Internship/Practicum Application

Please Review and Initial Indicating Your Understand and Agreement