Kaleidoscope Staff Application Form

Basic Information
Name *
Name
Home Address *
Home Address
Phone *
Phone
Birthdate *
Birthdate
Experience
Please list degrees (from most current to high school).
Please include ages of children, responsibilities, span of time you held these positions, and reason for leaving.
Have you completed any child care training courses?
Please list ten-year employment history below. Begin with the most current. Including the following: Dates (first to last), Name and Address of Employer, Position. If you were unemployed, please describe how you spent your time. Attach documentation of experience with working with children.
Further Information
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, any pre-employment testing, interviews and actual employment, but only if the program supervisor is made aware that an accommodation is required. If you are disabled and require accommodation, you may request it at any time during the interview process. You are obligated to inform the program director of your needs if it will impact your ability to perform the job for which you are applying.
If yes, expiration date:
If yes, expiration date:
I certify that all information on this application is correct. I have not given any false statement concerning my qualifications requirements. *
I certify that all information on this application is correct. I have not given any false statement concerning my qualifications requirements.
Signature
Date signed *
Date signed