Name

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Daytime Phone

(###)

###

####

Evening Phone

(###)

###

####

Availability to Work?

(Check One or More)

Days

Evenings

Weekends

Can You Make a One-Year Commitment?

Yes

No

Do You Have Your Own Transportation?

Yes

No

Do You Have a Valid Driver’s License? If Yes, Please Provide Your License Number

Yes

No

Initial here that we have your permission to check and obtain a report of your driving record and to share that information with those persons who will act on this Application?

Yes

No

Date Initialed

MM

DD

YYYY

Have you ever been charged with, convicted of, or plead guilty to a crime, either a misdemeanor or a felony (including but not limited to drug-related charges, child abuse, or other crimes of violence, theft or serious motor vehicle violations)?

Yes

No

Have you ever had to deal with a child abuse situation in any way, including being abused, being accused of abuse, knowing someone who was abused, etc.?

Yes

No

Reference 1

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

DayTime Phone

(###)

###

####

Evening Phone

(###)

###

####

Reference 2

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Daytime Phone

(###)

###

####

Evening Phone

(###)

###

####

Reference 3

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Daytime Phone

(###)

###

####

Evening Phone

(###)

###

####

Do we have your permission to contact these references as well as anyone else in order to obtain information about you for the purpose of considering you for a position of one who would work with children and / or youth?

Yes

No

Do we have your permission to share this information with those persons who will participate in acting on this Application?

Yes

No