Enrollment Applicant Information First, Middle, & Last Name Street Address Apt/Unit # City State Zip Code Phone # Email Address Date available to begin work Availability Social Security # D.O.B. Are you a citizen of the United States? YES NO - If no, are you authorized to work in the U.S? YES NO Have you ever been convicted of a felony? YES NO If yes, please explain Education/Child Care Experience High School City State Dates attended (Month/Year) To Did you graduate? YES NO Degree Obtained College CITY STATE Dates attended (Month/Year) To Did you graduate? YES NO Degree Obtained Other City State Dates attended (Month/Year) To Did you graduate? YES NO Degree Obtained References Please list three professional references. 1. Full Name Relationship Company Phone # Address 2. Full Name Relationship Company Phone # Address 3. Full Name Relationship Company Phone # Previous Employment 1. Company Phone # Address Supervisor Job Title Starting Salary Ending Salary Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? YES NO 2. Company Phone # Address Supervisor Job Title Starting Salary Ending Salary Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? YES NO 3. Company Phone # Address Supervisor Job Title Starting Salary Ending Salary Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? YES NO Other What do you feel most qualifies you for a position at our center? What are your professional goals? Disclaimer & Signature Acceptance I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. Date Send Message Contract Form Payment Plan Safe PARENT HANDBOOK Discipline Guidance Policy Form 2935 Admission Info Waiver of Claim
