Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

What type of employment are you seeking? *

Full Time (40 Hrs)

Part Time (up to 29 hrs)

Either

When would you be able to begin employment? *

Immediately

Within Two Weeks

Other(Specify in the blank below)

Are you 18 years of age or older and are you able to provide proof of eligibility to work in the United States? *

Yes

No

Have you ever filled an application by us before? *

Yes

No

Have you ever been employed by us before? *

Yes

No

Are you currently employed? *

Yes

No

Have you ever been convicted of a felony within the last 7 years? *

(Conviction will not necessarily disqualify you from work?)

Yes

No

If you did not complete high school, do you have a GED? *

Yes

No

N/A

Have you ever taken courses in child development?

Yes I have

No I have not

Have you ever taken courses in child care?

Yes I have

No I have not

Are you able to: *

(Strongly Agree for yes, Strongly Disagree for no)

Lift and hold a child?

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Run after a child?

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Sit on the Floor?

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Quickly stand from a seated position?

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Reference 1: *

First Name

Last Name

Phone 1 *

(###)

###

####

Reference 2: *

First Name

Last Name

Phone 2 *

(###)

###

####

Reference 3 *

First Name

Last Name

Phone 3 *

(###)

###

####

Date

MM

DD

YYYY

Please indicate which location you wish to apply for: *

Madison Heights

Leesville

Graves Mill

Rustburg

George St