Employment Form

* = Required Information

APPLICATION FOR EMPLOYMENT, VOLUNTEER, INTERNSHIP, PRACTICUM

Date

Name *

Maiden Name

Address *

City *

State *

Zip Code *

Email *

Home Phone *

Work Phone

Cell Phone *

POSITION APPLYING FOR (please mark all that apply):

Professional Child Care and Preschool Program:

Infant

Toddler

Preschool

School-age

Cook

Shuttle Bus Driver

Lead Teacher

Assistant Teacher

Floater

Administrator

Janitorial/Maintenance

Clerical

Errand Person

Volunteer

Other

School Services Division:

Consultant
What areas do you have specialization?

Tutor
What areas do you have specialization?

Availability

Part-time	Full-time
Flexible Hours	Long-term (a year or longer)
Short-term	Saturdays
Evenings

What hours and days are you available to work/volunteer:

SCHOOLS ATTENDED:

High School

School/Location

Graduation Date or Hours Completed

Area of Study/Major

Degree

College/University

School/Location

Graduation Date or Hours Completed

Area of Study/Major

Degree

College/University

School/Location

Graduation Date or Hours Completed

Area of Study/Major

Degree

REFERENCES (please do not list relatives):

Name - Title - Position

Contact Information (address and phone number)

Relationship

Name - Title - Position

Contact Information (address and phone number)

Relationship

Name - Title - Position

Contact Information (address and phone number)

Relationship

PAST WORK EXPERIENCE (last 5 years)

Place Contact Information

Date of Employment

Position/Responsibilities

Reason For Leaving

Salary/Hourly Wage

Place Contact Information

Date of Employment

Position/Responsibilities

Reason For Leaving

Salary/Hourly Wage

Place Contact Information

Date of Employment

Position/Responsibilities

Reason For Leaving

Salary/Hourly Wage

PAST RELATED WORK or VOLUNTEER EXPERIENCE WITH CHILDREN

Same as above

Place Contact Information

Date of Employment

Position/Responsibilities

Reason For Leaving

Salary/Hourly Wage

Place Contact Information

Date of Employment

Position/Responsibilities

Reason For Leaving

Salary/Hourly Wage

Place Contact Information

Date of Employment

Position/Responsibilities

Reason For Leaving

Salary/Hourly Wage

OTHER QUESTIONS

1. Are you at least 18 years of age (required by the Dept. of Health ):

Yes

2. Are you already registered as a child care provider in the state of Missouri?

Yes

3. Are you a certified teacher?

Yes

If yes, what areas are your certified to teach?

4. Do you have a CDA?

Yes

Renewal Date

5. Are you currently certified in infant and child CPR?

Yes

If yes, the expiration date:

6. Are you currently certified in First Aid?

Yes

If yes, the expiration date:

7. Date of your last TB test?

8. Have you had a medical physical within the last year with clearance to work with young children? (as required by the Dept. of Health ):

Yes

9. Have you ever been convicted of a crime? (please include traffic offenses)

Yes

If yes, please explain

10. Have you ever been accused of neglect or abuse?

Yes

If yes, please explain

11. Do you have a valid driver's license?

Yes

If yes, note any special type of license

Regular

Class-C

Class-B

Other

12. Are you able to lift at least 50 lbs.?

Yes

13. Do you smoke?

Yes

(The entire campus of The Education Institute, Inc. is a non - smoking and non - tobacco using campus. When on official business and representing the company, employees/consultants are also expected to refrain from using tobacco products in public in order to present a healthy image to our children. It is VERY IMPORTANT that no tobacco by - products are to be on clothes and hair when working with our young clients.)

14. What specialized skills , talents, or interests do you have that would enhance your position with The Education Institute (specialized training, foreign language, computer knowledge, music, art, drama, etc.):

15. What is your expected rate of pay for this position(s) you are applying?

Please feel free to include a current resume or vita, letters of reference, or other applicable information. You may also use a separate piece of paper to include additional information.

Attach Resume

The information contained within this application is presented as true and to the best of my knowledge.

Date