Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date Available *

MM

DD

YYYY

Are you applying for the on-site supervisor position or a staff position? *

On-Site Supervisor

Staff

I would do either (you must be qualified to be the on-site supervisor.)

Have you worked with children before? *

Yes

No

Have you ever been charged or investigated for child abuse, neglect, or endangerment? *

Yes

No

Are you or have you been certified in: *

CPR

First Aid

Mandatory Reporter

Universal Precautions

Do you have a valid drivers license and car insurance? *

Yes

No

Have you ever been arrested or convicted of a felony? *

Yes

No

Did you graduate? *

Yes

No

Did you graduate?

Yes

No

May we contact your previous supervisor for a reference?

Yes

No

May we contact your previous supervisor for a reference?

Yes

No

May we contact your previous supervisor?

Yes

No