Caregiver Application

If you are human, leave this field blank.

School-Age Care Program Employment Application

How did you hear about this job/referred by:

Are you work study qualified? (Yes or No)

Yes

First Name *

Last Name *

Middle Initial

Email *

Present Address (Street, City, State, Zip)

How many years have you lived at this address?

Primary Phone # (could be cell phone) *

Other Phone #

Date of birth (only if under 18):

Emergency Contact Name (First and Last) *

Emergency Contact Phone Number *

Seeking:

Full Time

Part Time

Hours Per Week

What hours and days of the week are you available to work? Important! Please BE SPECIFIC!

Do you have any physical limitations or unusual health conditions which would affect your ability to perform duties of any particular position? If yes please explain: