Application Employment Application * Name: First Last * Email: Other names you have worked under: * Job applying for: * Full Time Part Time * Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State ZIP Code * Primary Phone: * Are you a U.S. citizen? Yes No * Have you ever been convicted of a crime, including sex related or child abuse related offenses? (Exclude minor traffic violations for which the fine was under $50, offenses which were settled in juvenile court) * Do you have any physical conditioins that may restrict your performance of the job you are applying for? Any weight lifting limits? * Name of person to inform in case of emergency: * Emergency Contact Number: High School College/Trade Please include major, years attended, and degree. Awards or special certifications you have received? Do you currently have a CPR card or a First Aid card? Please list Date of your last physical exam: Early Childhood Courses Taken: Please include Course title, subject, and No. of Units. Special skills or talents which you may care to list: Example: Foreign Language, Typing, Swimming Instruction, Gymnastics, Computers, Musical Instruments, Art. Membership in a Professional Organization Please list Experience No.1 (work or volunteer) Please Include Employer, City, State, Job Description, Start and End date, Salary and Reason for Leaving. Experience No.2 Please Include Employer, City, State, Job Description, Start and End date, Salary and Reason for Leaving. Experience No.3 Please Include Employer, City, State, Job Description, Start and End date, Salary and Reason for Leaving. Experience No.4 Please Include Employer, City, State, Job Description, Start and End date, Salary and Reason for Leaving. References No.1 Professional (list at least two): Please include Name and Address, Title, Phone Number. References No.2 Professional: Please include Name and Address, Title, Phone Number. References No.3 Professional: Please include Name and Address, Title, Phone Number. Personal Reference: Please include Name and Address, Title, Phone Number. What do you feel most qualifies you for this position? What age(s) of children are you interested in working with? What are some of your work goals? If you could describe yourself in three words, what would those three words be? Additional Comments: * Are you willing to spend your own time and money to continue your education and to go through First Aid and CPR training, universal precautions, fingerprints, and food handler's certification? Yes No * 15 hours per year of Continued Education are required by the State of Colorado when working in Early Childhood. Discovery Kids will provide 6 hours of paid training. Are you willing to take the initiative to complete the additional 9 hours required using your own time and money? Yes No * Will you be able to provide a copy of immunizations (if you are under 18) and physical exam? Yes No The list of items above are mandatory and must be provided before employment. Resume Max file size is 32 MB. If you would like to upload a resume do so here. * Signature of Applicant and Date By clicking submit you certify that the above statements are true to the best of your knowledge, and you realize that any falsifying of information may result in termination. (Any applicant who knowingly or willfully makes a false statement of any material fact or thing in the application is guilty of perjury in the second degree as defined in section 18-8-503, R.R.S., and, upon conviction thereof, shall be punished accordingly.)