Employment Application FORM

Name(Required)

First Middle Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone Number(Required)

Email Address(Required)

Social Security Number(Required)

Are you at least 18 years old(Required)

Are you presently employed?(Required)

Do you have a valid driver's license?(Required)

Driver's License Number(Required)

Have you ever been convicted of a felony?(Required)

Please explain your felony.(Required)

Emergency Contact

(Please supply two, within a 45-mile radius of Sioux Falls)

Name

First Last

Phone Number

Relationship

Phone Number

Relationship

What Position are you applying for?(Required)

Employment Desired?(Required)

Preferred Age Group?(Required)

Availability

Date Available(Required)

How many hours on Monday?

How many hours on Tuesday?

How many hours on Wednesday?

How many hours on Thursday?

How many hours on Friday?

Are there any other obligations you have during the week that need to be considered for scheduling?

Education

School #1

Major / Specialization #1

Level or Degree Completed #1

Dates Attended #1

School #2

Major / Specialization #2

Level or Degree Completed #2

Dates Attended #2

School #3

Major / Specialization #3

Level or Degree Completed #3

Dates Attended #3

Please list any additional experience, schooling, qualifications or training:

Employment History

Start with your present or most current position and work backwards. If you were ever employed in any position under a different name, for each position give the name used.

Company #1

Company Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dates of Employment

Position

Supervisors

Number

Job Duties

Reason for Leaving

Company #2

Company Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dates of Employment

Position

Supervisors

Number

Job Duties

Reason for Leaving

Company #3

Company Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dates of Employment

Position

Supervisors

Number

Job Duties

Reason for Leaving

References

List three (3) persons not related to you, and who can furnish information about you. Do not repeat names of supervisors furnished in the employment record.

Name #1

First Last

Occupation

Phone Number

Name #2

First Last

Occupation

Phone Number

Name #3

First Last

Occupation

Phone Number

Are you or have you been known by a different name?

If so, please indicate name

First Last

Have you ever applied for employment or been employed at LifeChange Learning Center?

Do you have any relatives or friends working at LifeChange Learning Center?

Have you ever been convicted of a crime?

Have you ever served in any branch of the United States armed forces?

Are you currently on layoff status, leave of absence or other suspension of employment and subject to recall with another employer?

If you answered YES to any of the above, include details below:

How did you hear about us?

What do you consider to be a healthy childcare atmosphere?

Please give your Christian testimony:

Do you believe the Bible to be the ONLY inspired and infallible Word of God, our final authority in all matters of faith, truth and conduct?

I do not have any reservations when it comes to teaching and implementing Christian based curriculum?

If yes, please explain

Drug Policy

LifeChange Learning Center does not hire persons who use illegal drugs. Persons hired may be required to take and pass a strict screen for illegal drugs and may be subject to periodic tests for illegal drugs. LifeChange Learning Center has a strict no smoking policy, which includes in the parking lots, buses, and vans.

I certify that I (check one) do not use illegal drugs.

Agreement & Certification

I hereby certify that the facts set forth in this application (and accompanying resume) are true and complete to the best of my knowledge. I agree and understand that any misrepresentation of information or failure to disclose information during the employment process may disqualify me from further consideration for employment and if employed, will subject me to dismissal. If I am released under these circumstances, I further understand and agree that I will be paid and/or receive benefits only through the day of release. I understand that I must submit an Abuse and Neglect screening through the state of South Dakota Division of criminal Investigation and other state and federal authorities. I understand and agree that any offer of employment that I may receive from the center is conditioned upon the receipt of background information, including criminal background information. If employed, I agree to conform to all LifeChange Learning Center rules and regulations and Federal, State and local rules and regulations. In this regard, I understand that LifeChange Learning Center may, at its discretion, conduct searches of lockers, lunch boxes, tool boxes, clothing, purses, briefcases, vehicles, desks, work areas and other personal or LifeChange Learning Center property, and I hereby consent to such search. I also understand that if employed, my employment is for an indefinite period of time, that either LifeChange Learning Center or I may terminate my employment at will at any time, with or without cause or notice.

Signature(Required)