ATLANTA PREPARATORY

APPLICATION FORM FOR CHILD FACILITY PERSONNEL

DATE
POSITION DESIRED
DATE AVAILABLE

NAME (First) (Middle) (Last)
SPOUSE’S NAME
HOME ADDRESS HOME PHONE
BIRTHDATE SOCIAL SECURITY NUMBER

If you are under age 18, can you submit a work permit if hired?

If you are not a US citizen, do you have a VISA to work in the US?

If yes, what kind of VISA classification?
VISA Registration No: Expiration dat

Has bond or security clearance ever been denied and/or canceled? yesno

If yes, please explain:

EDUCATION (Attach documentation of qualifying education)

Elementary:

Secondary:

College:

Other:

Experience with groups of children (indication ages of children, your duties, dates of time you worked- in this position, reason for leaving)
Attach documentation of experience working with children.

HAVE YOU ATTENDED/COMPLETED ANY CHILD CARE TRAINING COURSES? yesno
IF YES LIST:

TEN YEAR EMPLOYMENT HISTORY, BEGIN WITH YOUR MOST CURRENT OR LAST EMPLOYER, IF YOU HAVE BEEN UNEMPLOYED DURING ANY TIME WITHIN THE PAST TEN YEARS, LIST HOW YOU SPENT YOUR TIME, e.g., STUDENT, HOUSEWIFE, UNEMPLOYED, ETC.

MONTH/YEAR NAME AND ADDRESS OF EMPLOYER POSTION
From
To
From
To
From
To

May we contact previous employers?

Do you have a criminal record? yesno
If yes, explain:

Have you ever been shown by credible evidence, e.g., a court order or jury, a department investigation or other reliable evidence to have abused, neglected or deprived a child or adult or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct? yesno
If yes, explain:

Under the Americans with Disabilities Act of 1991, this program is required to reasonably accommodate individuals with a disability. The reasonable accommodation requirement applies to the application process, any pre-employment testing, interviews and actual employment, but only if the program supervisor is made aware that an accommodation is required. If you are disabled and require accommodation, you may request it at any time during the interview process. You are obligated to inform the program director of your needs if it will impact your ability to perform the job for which you are applying.

Having read the job description for the position for which you are applying, are you in all respects, able to adequately perform the duties as described? yesno
If no, please explain:

Do you have a valid driver’s license? yesno
If yes, give the license number and class of license:

Have you had CPR training within the past two years? yesno
If yes, give expiration date:

Have you had first aid training within the past three years? yesno
If yes, give expiration date:

Atlanta Preparatory School Of The Arts requires annual child care training, are you willing to participate?

I certify that all information on this application is correct. I have not given any false statement concerning my qualification requirements.

Signature

Date

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