Raney Day Learning Center879 Freeport Rd Suite 105

Creighton PA 15030724-224-3737

We Require Random Dru!! Testin!!

We consider applicants for all positions without regard to race, color, religion, creed,gender, national origin, age, disability, marital or veteran status, sexual orientation orany other legally protected status. It is our intention that all applicants be givenequal opportunity and that selection decisions are based on job related factors.

Date:

Last Name First Name MIStreet City Zip Code

Address:Telephone# Home Cell Social Security Number:

(H) (C)Are you legally eligible to work in the United States? Y NProof of citizenship or immigration status will be required upon employment

Are you 18 years of age or older? Y N (must be 18 to work in a childcare facility)Have you ever been convicted of a criminal offense other than minor traffic violations?

A criminal conviction will be considered only in relation to the job for which you areapplying. Seriousness and nature of the offense, time elapsed, and rehabilitation will betaken into account. Notwithstanding, no person may be a staff member of a daycarecenter who has been convicted of a crime against children.

Do you have any past or pending reports of child abuse, maltreatment or neglect? Y N

How did you hear of the position?

Position Appling for:Director Assistant Director Group Supervisor Assistant Group Supervisor Aide

Date Available: Salary Desired $

Number of hours desired per day: Week:

Please fill in the hours you are available to work:

Monday

Tuesday

Wednesday

Thursday

Friday

Will you work overtime is asked? Y N Can you come in early if called Y N

Can you fill in for call off s? Y N Can you stay late if needed Y N

Have you worked with children before? Y N

If YES: What age groups did you work with? _

What did you like best about the experience? _

What did you like least about the experience? _

Would you be willing to assist in the kitchen? Y NDo you have any physical or mental limitations that may give you problems whenperforming the attached duties? Y N If yes, please explain:

[REFFERENCES: Name Relationship Phone Number

1.

2.

3.

EMPLOYMENT HISTORY1. Present Company name

Address Phone

Position Duties

Employed From To Salary Start Finish

Reason for leaving

May we contact employer? Y N Number of days called off in a month?

2.Company name

Address Phone

Position Duties

Employed From To Salary Start Finish

Reason for leaving

May we contact employer? Y N Number of days called off in a month?

3.Company name

Address Phone

Position Duties

Employed From To Salary Start Finish

Reason for leaving

EDUCATIONCollege

# Of years attended Graduate Y N Degree

Major area of study

2. Technical School

# Of years attended Graduate Y N Degree

Major area of study

3.High School

Highest grade completed Year of Graduation Degree

List all other certifications, licenses, and training, CPR, First Aid, Fire Safety, Lifeguardand etc. you consider relevant to employment

I hereby authorize investigation of all statements in this application including references.I certify that such statements are true, and understand that misrepresentation or omissionof facts called for in this form is cause for termination of employment without notice. Ialso agree, if employed, to abide by all regulations of the PA Department of Welfare andrules of Raney Day Learning Center.

Signature Date

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