Tutor Application
Full Name
*
First Name
Last Name
Gender
Male
Female
Current Age
*
Marital Status
*
Street Address
*
City, State, Zip
*
E-mail
*
Be sure to list one you check regularly
Phone Number: Best one to contact you
*
-
Area Code
Phone Number
Occupation
*
Name of Employer
*
Number of Years At current employer
*
Emergency Contact
*
Relationship
Phone (Emergency Contact)
*
Are you available Tuesday and Thursday afternoons?
Please Select
Yes
No
What is the earliest time and latest time you are available on Tuesday and Thursday afternoons?
T-Shirt Size
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
Other
Have you received certification in any of the following?
CPR
First Aid
Counseling or Therapy
Teaching Certification
Do you have previous background or training in working with children who have been abused or neglected?
Yes
No
If yes, in what way?
Were you a victim of abuse, neglect, or abandonment as a minor?
Yes
No
Yes, but I would prefer to discuss this in person
If yes, please clarify
Please describe why you wish to be a part of the James Samaritan Homework Helper program and work with children of abuse, neglect, and abandonment
Medical History
Do you have any medical, emotional, or mental health conditions?
No
Yes
If yes, please describe:
Have you had any serious illness, injuries, or medical operations in the last three years?
Yes
No
If yes, please list:
Education
High School Name
*
Date of Graduation
*
College
College Major
Date of Graduation
Other Education
Personal References (required for first time staff only) Not relatives.
References will be contacted via email, so please be sure to list the correct email address and notify your references. They will receive the email with the link to the reference form when you submit this application.
Reference #1
First Name
Last Name
Reference #1 Email
example@example.com
Reference #2
First Name
Last Name
Reference #2 Email
example@example.com
Reference #3
First Name
Last Name
Reference #3 Email
example@example.com
Personal Profile
Have you committed your life to Jesus Christ and received his free gift of forgiveness from your sins?
*
No
Yes
Where & When:
*
What church do you presently attend?
*
For how long?
Pastor's Name
*
List three strengths you have in working with children: Please be specific
*
List three weaknesses you have in working with children: Please be specific
*
I would prefer my students to be in:
Elementary School
Middle School
High School
Any Age
Have you ever been arrested for a criminal offense?
*
No
Yes
Have you ever been convicted or plead guilty to a crime?
*
No
Yes
Have you ever been arrested for sexual misconduct?
*
No
Yes
Have you ever been convicted of or plead guilty to sexual misconduct?
*
No
Yes
Have you ever taken drugs other than prescription drugs?
Yes
No
If you answered "yes" to any of the above, please explain:
The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in this application to give you any information (including opinions) that they may have regarding my character and fitness for working with children. I hereby release any individual, church, youth organization, charity, employer reference, or any other person or organization, including record custodians, both collectively and individually from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply with this authorization. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application.
No
Yes
I have carefully read the foregoing release and know the contents thereof and I sign this release of my own free act. This is a legally binding agreement which I have read and understand.
Yes
No
Thank you for your interest in being a part of the James Samaritan Team!
By submitting this form you give us permission to contact your references and begin the screening process.
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