Southwest School Corporation Application

Applicant Information

Southwest School Corporation
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Name of Emergency Contact*

First NameLast Name
Emergency contact's place of employment*
Emergency Contact Phone Number*
Please enter a valid phone number.
Substitute's Date of Hire
If applicable
In case of emergency involving you what doctor should be contacted? *
Doctor's Phone Number*
Please enter a valid phone number.
If above doctor is not available, what doctor should be contacted?
If applicable
Doctor's Phone Number
If applicable
Are you allergic to any medication?*

YesNo
If yes, please list:
If applicable
Additional family or persons to contact in case of an emergency.
Name and Phone Number
Additional family or persons to contact in case of an emergency.
Name and Phone Number

Certified Position

Complete this section if applying for any of the following: Teacher, Counselor, School Nurse or Administrator
Do you plan to apply for an of the following positions: Paraprofessional (Teacher's Aide) or Bus Driver

YesNo
Major*
No. of Hours*
Minor*
No. of Hours*
Are you currently under a contract to teach?*

YesNo
List any endorsements you hold:*
If applying for a high school or junior high position, what subjects are you licensed to teach in Indiana?*
If teaching experience is less than 3 years please indicate where you student taught?*
At what grade level did you student teach?*
Which extra class activities (including intra-murals or interscholastic athletics) are you willing to direct?*
Do you hold a valid Indiana License?*

YesNo
What type(s):*

Initial Practitioner LicenseProficient Practitioner LicenseSubstitute Permit
Indiana License Number:*
Upload license (s) here. *

Cancelof
Upload cover letter and resume here*

Cancelof
Upload three letters of recommendation here.*

Cancelof

Applying for Substitute Teacher License

If you do not have a substitute teacher license, complete the steps below to apply.
If you do not already hold an Indiana substitute teaching license, please apply through the Indiana Licensing Verification and Information System (LVIS) at https://license.doe.in.gov/SignIn?returnUrl=%2F.

Create or log in to your LVIS account, select Apply for a License, choose Substitute Permit, complete the application, upload any required documentation, and submit the licensing fee. You may log back into LVIS at any time to check the status of your application.

See the user guide below for more detailed directions.
LVIS User Guide

Substitute Teacher Policy Acknowledgement and Agreement
ACKNOWLEDGEMENT, AGREEMENT, AND RECEIPT

OF

SUBSTITUTE TEACHER POLICY; DRUG FREE WORKPLACE POLICY; ANTI-
HARASSMENT POLICY; STAFF TECHNOLOGY AND ACCEPTABLE USE AND
SAFETY POLICY; USE OF SOCIAL MEDIA POLICY

The undersigned hereby acknowledges receipt of a copy of the Substitute Teacher Policy; Drug-Free Workplace Policy; Anti-Harassment Policy; Staff Technology and Acceptable Use and Safety Policy; and Use of Social Media Policy. The undersigned hereby acknowledges and agrees that nothing contained in the policies including practices, and benefits stated herein are intended to create any contractual right, express or implied, to employment or to any particular term or condition of employment. We retain the right to revise, amend the policies or terminate any policies unilaterally without notice at any time and the Employee’s continued opportunity to work in Southwest School Corporation will be deemed acceptance of such revisions and modifications.
Employee's Signature*

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Date*

MonthDayYear
Date

Acknowledgement of Mandated Reporter Status

Southwest School Corporation
I understand that when I am working and/or volunteering for Southwest School Corporation in my official capacity and/or professional:

I will become a mandated reporter under the Abused and Neglected Child Reporting Act (IC 31-33-5 and IC 12-17.2-3-5). This means that I am required to report or cause a report to be made to the child abuse and neglect hotline number at 1-800-800-5556 whenever I have reasonable cause to believe that there is or may be professional or official capacity may be abused or neglected. I understand that there is no other way of calling the hotline number and that the hotline operates 24-hours per day, 7 days per week, 365 days per year.

I understand that in an effort to help mandated reporters understand their critical role in protecting children by recognizing and reporting child abuse/neglect, Department of Child Services administers an online training course, available 24 hours a day, seven days a week.

I further understand that the privileged quality of communication between me and my patient or client is not grounds for failure to report suspected child abuse or neglect. I know that if I willfully fail to report suspected child abuse or neglect, I may be found guilty of a Class A misdemeanor. This does not apply to physicians who will be referred to the State for action.
Sign and date below to affirm that you have read this statement and have knowledge of the reporting requriements, which apply to me under the Abused and Neglected Child Reporting Act.
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

	Dates	Type of Accident (Head -on, Rear-End, Overturn)	Fatalities	Injuries
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	Dates	Location	Charge	Penalty
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	State	License No.	Type	Expiration
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	Not Interested	Somewhat Interested	Very Interested
Elementary
Middle School
High School

Applicant Information

Employment Application

United States Military Service

Education and Training:

Work Experience

Professional References

Criminal Background Disclosure, Certification, and Authorization

Certified Position

School Bus Driver Position

Past Employers Requiring CDL:

Substitute Teaching Position

Applying for Substitute Teacher License

Substitute Teacher Policy Acknowledgement and Agreement

Acknowledgement of Mandated Reporter Status

	First and Last Name	Relationship
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	Name and Location of School	Years	Degree/Major
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	Name	Address, City State	Position	Phone #
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