Job Application Form

Job Application

Please complete the form below to apply for a position with us.
Full Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Phone Number*
Social Security Number*
Emergency Contact*

First NameLast Name
Emergency Contact Information*
Please enter a valid phone number.

Medical Information
Primary Doctor Name
Primary Doctor Phone Number
Please enter a valid phone number.
Preferred Hospital
Any known allergies*
If yes, briefly describe*

Work Availability
Select all that apply*

Full Time EmploymentPart Time EmploymentSeasonal EmploymentOther
Position Applied*
How did you hear about us
Available Start Date*

MonthDayYear
Best Time to call
Times available for an Interview

Eligibility for Employment
Are you legally eligible for employment in the United States?*
Proof of US citizenship or immigration status will be required upon employment
Have you been convicted of a felony?*
Proof of US citizenship or immigration status will be required upon employment

Previous Work History
Name of Employer #1
Phone Number
Please enter a valid phone number.
Immediate Supervisor
Job Title
Dates of Employment
Starting Wage
Ending Wage
Description of Job Duties
Reason for Leaving
Name of Employer #2
Phone Number
Please enter a valid phone number.
Immediate Supervisor
Job Title
Dates of Employment
Starting Wage
Ending Wage
Description of Job Duties
Reason for Leaving

Work References
Name of Work Reference #1*
Years Known*
Phone Number*
Name of Work Reference #2*
Years Known*
Phone Number*
Name of Work Reference #3*
Years Known*
Phone Number*

Education & Experience
Highest Level of Education Completed*
Have you ever worked in a licensed child care facility?*
If yes, please list all locations (Name of Center, Address, Phone Number, Direct Supervisor)
Have you taken any college courses or trainings related to child care, nutrition or education? If yes, please list below
Describe your experience working with children of different ages
Have you completed Pediatric CPR & 1st Aid in the past 2 years?*
Have you completed a Physical in the last year?*
Have you had a negative TB Test taken in the last year?*
What motivated you to pursue a career in the child care setting?
Upload Your Resume

Cancelof
It is understood and agreed upon that any misrepresentations by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed.

I give the employer the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the employer and its representatives for seeking such information, all other persons, and corporate organizations for furnishing such information.

The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any application’s consideration for employment on a basis prohibited by local or federal law.

This application is current to only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time with or without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurance to the contrary.
Signature*

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