Do you have a:

 High School Diploma

 GED Certificate

 CDA

 College Degree

College Degree (Assoc,. Bachelor, Masters)?*

Number of ECE Credits*

Do You have specialty certificates?

 Child Care

 Director

 Pediatric First Aid

Do you have a Professional Development Record?*

 Yes

 No

Are you a T.E.A.C.H. Scholarship Participant?*

 Yes

 No

Have you had Fire safety training during the last year?*

 Yes

 No

Do you have a current (1 year or less) State police clearance?

 Yes

 No

Do you have a current (1 year or less) FBI clearance?

 Yes

 No

Do you have a current (1 year or less) Child Line abuse clearance?

 Yes

 No

Do you have a current (1 year or less) Staff Health Appraisal?

 Yes

 No

Do you have a current (1 years or less) TB shot?

 Yes

 No

Are you familiar with DPW regulations for early learning centers?

 Yes

 No

Character References:
Please list three non-relatives who we may call to verify your character.

(Reference 1) Name

(Reference 1) Phone Number

(Reference 1) Years acquainted

(Reference 2) Name

(Reference 2) Phone Number

(Reference 2) Years acquainted

(Reference 3) Name

(Reference 3) Phone Number

(Reference 3) Years acquainted

Child Care Experience
Please list experience in the education / child care field only. This can include positions at centers, schools or private babysitting.

Employer

Employment Period

Supervisor

Employer Phone Number

Age of children in your care

Number of children cared for

Job Duties

Reason for leaving