Polk Street Methodist Church

Applicant Information

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Email

Date Available

Social Security #

Position applied for

Childcare experience?

Yes

No

If yes, please list under previous employment

Are you a citizen of the United States?

Yes

No

Have you ever worked for this center?

Yes

No

If yes, when?

Have you ever been convicted of a felony?

Yes

No

If yes, please explain.

Education

High School

Did you graduate?

Yes

No

Graduation Date

College

Did you graduate?

Yes

No

Graduation Date

Degree

Other (GED or Vocational School)

Did you graduate?

Yes

No

References

Please list three (3) personal references

1

First Name

Last Name

Relationship

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

2

First Name

Last Name

Relationship

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

3

First Name

Last Name

Relationship

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Any additional comments that might be helpful. (optional)

Previous Employment

Company

Phone Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Supervisor

Job Title

Responsibilities

Start Date

End Date

Reason for leaving

Company

Phone Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Supervisor

Job Title

Responsibilities

Start Date

End Date

Reason for leaving

Company

Phone Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Supervisor

Job Title

Start Date

End Date

Reason for leaving

Special Training or Classes

Training or Class

Start Date

End Date

How will this training/class help this position?

Are you certified in pediatric first aid and CPR?

Yes

No

If yes, when does your certification expire?

Special childcare certifications? Please list:

Disclaimer & Signature

I certify that my answers are true and complete to the best of my knowledge.

I understand that a background check must be completed for employment at Polk Street Child Development Center.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

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