DATE - Indelible Impressions Learning Center

Indelible Impressions Learning Center Employment Application“More than a nursery, but a ministry!”DATE____________________________________POSITION APPLYING FOR__________________________________________________________________________________________________________________________________________________NAME (FIRST) (MIDDLE) (LAST)______________________________________________________________________________________________________________HOME ADDRESS CITY ZIP CODE______________________________________________________________________________________________________________HOME PHONE CELLULAR PHONE EMAIL ADDRESSIf you are under the age of 18, can you submit a work permit if hired? _____________ Yes _____________ NoIf you are not a US citizen, what is your Visa registration number? ________________________ Expiration date __________________If yes, what kind of VISA classification do you have? __________________________________________________________________Has bond or security clearance ever been denied and/or cancelled? ________________Yes_______________NoIf yes, please explain:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________EDUCATION (Attach documentation of qualifying education)PLACE DATES DIPLOMA, CERT. OR DEGREEHigh School______________________________________________________________________________________________________________College______________________________________________________________________________________________________________Other____________________________________________________________________________________________________________________________________________________________________________________________________________________________WORK EXPERIENCETen year work employment history. Begin with your most current or last employer. If you have been unemployed during anytime withinthe last ten years, list how you spent your time. (Student, homemaker, unemployed, etc)Month/Year Name & Address of Employer Position Reason for Leaving________ to ________________ to ________________ to ________________ to ________________ to ________Page 1 of 3

Indelible Impressions Learning Center Employment Application“More than a nursery, but a ministry!”May we contact your previous employers? _______ Yes _______ NoExperience with groups of children (Indicate ages of children and your position)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Attach documentation of working with childrenChild Care Training Workshops AttendedEarly Childhood Education/Child Development College Courses TakenAre you planning to further your education? ______No ______Yes When? ________________In the state of Georgia, childcare personnel are required to complete orientation and 10 hours of training annually. Do you agree tocomply with this rule and costs? _____ Yes _____ NoDo you have current evidence of successful completion of CPR training? _____ Yes _____ NoDo you have current evidence of successful completion of first aid training? _____ Yes _____ No______________________________________________________________________________________________________________PHYSICAL RECORDDo you have any physical handicap, mental health disorder which would interfere with your ability to perform adequately the assignedjob duties for which you are applying, or personal limitations on the type of work you can do with children at school or the amount oftime you can spend at work: _____No _____YesIf yes, please explain:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Childcare workers are required to be in good health and free from tuberculosis. A statement from your physician may be required. Doyou agree to comply with this rule? _____ Yes _____ NoAre you able to lift a child up to 40 lbs in weight? _____ Yes _____ NoDate of last physical exam ___________Page 2 of 3

Indelible Impressions Learning Center Employment Application“More than a nursery, but a ministry!”Under the Americans with Disabilities Act of 1991, this program is required to reasonably accommodate individuals with a disability.The reasonable accommodation requirement applies to the application process, pre-employment testing, interviews, and actualemployment, but only if the program supervisor is made aware that an accommodation is required. If you are disabled and requireaccommodation, you may request at any time during the interview process. You are obligated to inform the program director of yourneeds that will impact your ability to perform the job for which you are applying.______________________________________________________________________________________________________________CRIMINAL RECORDI have never been shown by credible evidence, e.g., a court or jury, an Office investigation or other reliable evidence to have abused,neglected or deprived a child or adult or have subjected any person to serious injury as a result of intentional or grossly negligentmisconduct as evidenced by an oral or written statement to this effect obtained at the time of application.________ No, I do not have a criminal record.________ Yes, I have a criminal record.If yes, please explain:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________I understand that I am required to submit a satisfactory criminal background check if a position is offered to me. _____ Yes ____ No______________________________________________________________________________________________________________ACKNOWLEGEMENT OF PROFESSIONAL EMPLOYER ORGANIZATION RELATIONSHIPPlease be informed that we utilize the services of a Professional Employer Organization (PEO). If hired by this worksite“Indelible Impressions Learning Center” you will be a leased employee from the designated PEO. Your human resourcesneeds such as: benefits, payroll, taxes, and workman’s compensation will all be handled by the assigned PEO. If hired Iwill be required to follow the rules and regulations of the work site “Indelible Impressions” as well as the policies andprocedures as outlines in the PEO’s Employee Handbook.___________________________________________________________________________________________________SIGNATURE CONFIRMATIONIndelible Impressions Learning Center is a faith based “Christian” organization. If hired by this work site you will berequired to participate in Christian activities. These activities include but are not limited to teaching scripture and biblestories, participating in group prayer and chapel, and leading prayer before meals.We do not discriminate based on race, sex, color, national origin, age, or disability. We endeavor to make reasonableaccommodations, as required by law, for known and obvious physical and mental disabilities of otherwise qualifiedemployees and applicants unless an accommodation would impose undo hardship on our business.I certify that all information on this application is correct. I have not given any false statement concerning my qualificationrequirements. I understand that providing false information on this application will lead to immediate termination ofemployment if I am hired.I certify that I have received a copy of the teacher job description. If hired I am responsible for performing duties asoutlined in the job description as well other duties as assigned.Applicant’sSignature__________________________________________________________________________Date:______________________Page 3 of 3