Radcliff United Methodist Church

Childcare Worker Application

 

Date: 

 

Name:     

 

Birth date: 

 

E-mail address: 

 

Current Address:    

 

Length of time at this address: 

 

Home phone:     Cell phone: 

 

Previous Address: 

 

Education:  Starting with high school, list all education:

 

School:    City/State:   

 

          Years Attended:    Diploma/Degree: 

 

 

School:    City/State:   

 

          Years Attended:    Diploma/Degree: 

 

 

School:    City/State:   

 

          Years Attended:    Diploma/Degree: 

 

List all training/certification completed, with date of completion (i.e.  CPR, childcare certification classes, etc.) 

 

Prior Experience:  Include any type of paid & volunteer service, (related to childcare):

 

Name of Organization:    City/State:   

 

                    Job title:    Years at Job: 

     

       Direct Supervisor:    Phone Number: 

 

 

Have you been convicted of a violation of the law?  Yes No   If yes, explain: 

 

Do you have, or have been treated for a mental disorder, or physical disability that could affect your ability to work with children?  Yes No  

If yes, explain: 

 

What days and nights are you available?  What days and nights are you definitely not available? 

 

Do you have transportation?  Yes No

 

References:  3 persons over 21 years of age who are unrelated to you:

 

Reference #1: 

 

Reference #2: 

 

Reference #3: