Name

PERSONAL INFORMATION

Last Name *

First Name *

Middle Name

Social Security # *

Former Name(s):

Home Address

Address Line 1 *

City *

Apt #

State *

Street

ZIP *

Cell Phone *

Email Address *

Are you available for overtime? *

Yes

Alternate Phone

Driver’s License

Date of Birth: *

Position Desired: *

Date Available: *

Rate of Pay Desired: *

Days/Hours Available: *

Full Time Part Time

What prompted your application to The Kid’s Corral?

Newspaper Ad

Internet Search

Drive By

Friend Referral

Job Fair

College

Employee Referral

Have you been employed by The Kid’s Corral? *

Yes No

If yes, give date:

EDUCATION AND TRAINING

Circle Last Grade Completed

High School *

9 10 11 12

College

1 2 3 4 5 6

High School Name *

College Name

Graduate School Name:

Other School Name

High School Address: *

College Address

Graduate School Address:

Otehr School Address

List any Special Skills/Additional Training/Certifications:

EMPLOYMENT HISTORY

LIST PRESENT OR LAST EMPLOYMENT FIRST. “SEE RESUME” IS NOT ACCEPTABLE.

Employer 1

Employer:

Immediate Supervisor:

Job Title

Brief Description of Duties

Phone #

Address

City/State/Zip

EMPLOYMENT DATES

From

HOURLY OR ANNUAL SALARY

Start

Final

Reason For Leaving

Account for Period Between Jobs:

EMPLOYMENT HISTORY

Employer 2

Employer

Immediate Supervisor

Job Title

Brief Description of Duties

Address

City/State/Zip

Phone #

EMPLOYMENT DATES

From

HOURLY OR ANNUAL SALARY

Start

Final

Reason for Leaving

Account for Period Between Jobs

EMPLOYMENT HISTORY

Employer 3

Employer

Immediate Supervisor

Job Title

Brief Description of Duties

Address

City/State/ZIP

Phone

EMPLOYMENT DATES

From

HOURLY OR ANNUAL SALARY

Start

Final

Reason for Leaving

Account for Period Between Jobs

May we contact your current employer? *

Yes No

Do you have any friends or relatives employed at The Kid’s Corral? *

Yes No

If yes, list the names and relationship:

REFERENCES

Please list three persons whom The Kid’s Corral can contact and who are able to evaluate your knowledge and ability. DO NOT list current The Kid’s Corral employees or personal friends. These should be individuals who supervised your work.

REFERENCE 1

REFERENCE 2

REFERENCE 3

Describe the duties of each position you have held that were in the areas of children services, childcare
personnel supervision and program management or administration.

Describe Duties of each position

List any Professional Licenses, Certifications or Credentials that you hold:

Describe any other experience you have had which you feel is pertinent. Include volunteer work as well. Please include dates and locations.

HEALTH INFORMATION

Are you physically and emotionally fit to work in a childcare facility? *

Yes No

If no, please explain

Are you physically and/or emotionally impaired? *

Yes No

If yes, please explain

EMPLOYMENT ELIGIBILITY

Applicants must successfully complete drug testing, background investigation, and show proof of educational credentials.

Are you legally authorized to work in the United States? *

Yes No

Type of Visa:

Have you ever been charged or convicted of a felony or misdemeanor? *

Yes No

If yes, please list:

Do you have any previous or pending allegations of sexual or physical abuse? *

Yes No

Have you ever been investigated for abusing or neglecting a child by any of the following agencies?

Child Protective Services of the Texas Department of Family and Protective Services *

Yes No

County Child Welfare Agency *

Yes No

Law Enforcement Agency (Police, Sherriff, etc.) *

Yes No

Child Welfare Agency in another state *

Yes No

Other (specify)

If yes to any of the above

what was the child’s name?

When did this occur?

Where did this occur?

How was the child related?

Have you ever been arrested, charged or convicted of a felony or misdemeanor? *

Yes No

If yes, date of conviction(s):

Location(s):

Give details, including type of conviction and disposition:

Do you have any felony or misdemeanor charges pending with the county or district attorney or is anyone now complying with the terms of a deferred adjudication? *

Yes No

If yes, type of charg(s):

County where charge(s) are pending or length of deferred sentence:

Location(s):

Court No.

I certify that this information contains no willful misrepresentations or falsifications and that it is true and complete to the best of
my knowledge and belief. I hereby authorize The Kid’s Corral to contact the persons listed on this form. I understand that The
Kid’s Corral may contact others, and at any time, seek verification of any and all information on this form.

Signature *

Date *

Submit form to: *

Providence Campus Savannah Campus

Employment Application Form

PERSONAL INFORMATION

Home Address