Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

Reference #1

First Name

Last Name

Reference #1 Phone Number

(###)

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Reference #2

First Name

Last Name

Reference #2 Phone Number

(###)

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Reference #3

First Name

Last Name

Reference #3 Phone Number

(###)

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I understand that I will have to complete a drug screen, fingerprints, background check if hired and all employment is contingent on these items. *

Yes

No

In the last 5 years, have you been arrested for, charged with, or convicted of, been imprisoned, been on probation, or been on parole for any offense(s)? Include all offenses where you have been found guilty, pled guilty or nolo contendere (no contest). (Leave out traffic fines of less than $150.00) *

Yes

No

Are you now under charges for any violation of law? *

Yes

No

During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, or did you leave any job by mutual agreement because of specific problems? *

Yes

No

Have you ever been accused of, arrested for, or charged with a crime involving a child? *

Yes

No

Have you ever been found guilty of, or entered a plea of nolo contendere (no contest) or guilty to, any felonious offense, or any of two or more misdemeanor offenses under Federal, State, or tribal law involving crimes of violence; sexual assault, molestation, exploitation, contact or prostitution; crimes against persons; or offenses committed against children? *

Yes

No

In the last 5 years have you illegally used any controlled substance, for example, marijuana, cocaine, crack cocaine, hashish, narcotics (opium, morphine, codeine, heroin, etc.), amphetamines, depressants (barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.), or illegally used prescription drugs? *

Yes

No

Have you ever been accused of, suspected of, or charged with any of the following or anything similar; attempted suicide, neglect of a dependent, any sexual offense, battery, or child abuse. *

Yes

No

While in a child care setting, have you ever been the subject of disciplinary action, or been the part responsible for a childcare facility receiving an administrative fine or other disciplinary action? *

Yes

No

On Which of The Following Do You Have Current Training?

Choose All That Apply

CDA

Early Childhood Degree

I understand this is a minsitry of Shelbyville Community Church and all core values at SCC will be followed by all KPC Staff. *

https://insidescc.org/beliefs

Yes, I understand

No

I am willing to work in a discipleship work environment where we will walk in and toward a relationship with Jesus daily together as a staff. *

Yes

No

Electronic Signature

First Name

Last Name