Child Provider Employment Application

Child Provider Employment Application
Name

First NameLast Name
Date

MonthDayYear
Date
SSN(Last 4)
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Availability
Days Available

MondayTuesdayWednesdayThursdayFridaySatrurdaySunday
Hours Available
Available for Overtime or Weekends?
Do you have reliable transportation?
Employment History
Employer:   Type a label
Phone:   Area Code   Phone Number
Job Title:    Type a label
Pay Rate:   Type a label
Date Employed:   Date
Reason for Leaving:   Type a label
Employer:   Type a label
Phone:   Area Code   Phone Number
Job Title:    Type a label
Pay Rate:   Type a label
Date Employed:   Date
Reason for Leaving:   Type a label
Certifications and Experience
Do you have two or more years experience?

YesNo
Do you have a CDA?

YesNo
Do you have experience with young toddlers or preschoolers?

YesNo
FBI Clearance?

YesNo
Nsors sex offender clearance ?

YesNo
State Police clearance ?

YesNo
Child Abuse Clearance ?

YesNo
Background Information
Have You Ever Been Convicted of A Felony

YesNo
If Yes, Please Explain:
Are You Authorized to Work in The U.S:

YesNo
References
Name:   First Name   Last Name
Phone:   Area Code   Phone Number
Relationship:   Type a label
Name:   First Name   Last Name
Phone:   Area Code   Phone Number
Relationship:   Type a label
Acknowledgement and Signature

I certify that the information provided is true and complete. I authorize Lil Ummi Steam Academy to verify any information and contact past employers and references.
Signature

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Date

MonthDayYear
Date
Should be Empty:

Child Provider Employment Application

Emergency Contact Information

Availability

Employment History

Certifications and Experience

Background Information

References

Acknowledgement and Signature