ࡱ>  nLbjbj[[ 899%Cwk;;8$n1,,,0000000$f25r1!5* ",5*5*1;;](1).).).5*p;80).5*0).).:]0,s0c&e*0 0>10n10 z5),Bz50z500,().&"Tz%,,,11k-,,,n15*5*5*5*z5,,,,,,,,, :  Todays Date _________________ Position Desired ___________________________________ Position Applying for _______________________________ (Age group of children best trained/most experienced) a. Infants _ b. Toddlers _ c. Two to three year olds _ d. Four to five year olds _ e. School age __ Personal and General Information Last Name First Name Middle Name Maiden Name ____________________________________________________________________________________________ Street Address City State Zip Area Code/Telephone ____________________________________________________________________________________________ Social Security Number Drivers License Number (State and Expiration Date) ____________________________________________________________________________________________ Are you at least 19 years old? ___ Yes __ No Emergency Information: Name of Person to Contact in Case of Emergency: _________________________________________________________ Address __________________________________ Telephone No. _______________________________________ Name of Physician _______________________ Telephone No. _________________________________ Address _____________________________________________________________________________________ Education Schools AttendedName and Address of SchoolDates AttendedGEDDiplomaCertificateDegreeHigh School College Graduate Other  Child Care Training List all courses, workshops, conferences related to child development, early childhood education and administration/management of day care centers. Attach additional pages if necessary. Attach copy of course/workshop certificate. Title of course/Workshop Sponsor Date (s) Employment History List in order beginning with most recent employment. Attach additional pages if necessary. Employer Street Address, City, State, Zip Your Job Title Supervisor Name and TitleDescription of Duties: From (Mo. /Yr. ) To (Mo. / Yr.) PresentReason for Leaving  Employer Street Address, City, State, Zip Your Job Title Supervisor Name and Title Description of Duties: From (Mo. /Yr. ) To (Mo. / Yr.) Reason for Leaving  Employer Street Address, City, State, Zip Your Job Title Supervisor Name and Title Description of Duties: From (Mo. /Yr. ) To (Mo. / Yr.) Reason for Leaving  Employer Street Address, City, State, Zip Your Job Title Supervisor Name and Title Description of Duties: From (Mo. /Yr. ) To (Mo. / Yr.) Reason for Leaving  Employer Street Address, City, State, Zip Your Job Title Supervisor Name and Title Description of Duties: From (Mo. /Yr. ) To (Mo. / Yr.) Reason for Leaving  References List three persons whom we may contact as references. One should be a former employer or a teacher if not previously employed (exclude relatives)_________________________________________________________________________________________________________ Name (Last, First, Middle) Address (City, State, Zip) Area Code/Telephone No. ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Have you ever been arrested, charged, or convicted of a criminal offense? Yes___, No ___. If yes, give details ____________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Have you ever received treatment/counseling from a psychologist/psychiatrist/counselor? Yes ___ No ___. If yes, give details. ________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Do you or have you ever received treatment for drugs/alcohol abuse? Yes ___ No ___. If yes, explain. _____________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Have you ever been investigated for suspected child abuse/neglect? Yes ___ No ___. If yes, explain. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Can you meet the essential functions of this job? ___________________________________________________________ Are you related to anyone employed by Union Chapel Daycare Center? If yes, give name of person (s). ____________________________________________________________________________________________ Are your religious beliefs sufficiently compatible with those of Union Chapel Missionary Baptist Church that you could conduct a developmentally appropriate Biblically based program of study? ____________ Write the name and address of the church you are currently a member of, the pastors name and a statement attesting to your salvation: _____________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ This application is not complete without the following: A physicians statement attesting to your general fitness for the job, your freedom from infectious disease, and a record of negative test for tuberculosis: A Request for Clearance of State Registry on Child Abuse/Neglect by the Alabama Department of Human Resources; A Criminal History Information Consent and Release Form Documentation of the highest level of education indicated on the application. Waiver and Consent form signed. Waiver and Consent: I, _______________________________________________________ , hereby certify that the information I have provided on this application for employment is true and correct. I authorize this church to verify the information I have provided on this application by contacting the references and employers I have listed, by conducting a criminal records check, or by other means, including contacting others whom I have not listed. I authorize the references and employers listed in this application to give you whatever information they may have regarding my character and fitness for the job for which I have applied. Furthermore, I waive any rights I may have to confidentiality. In the event that my application is accepted and I become employed by Union Chapel Missionary Baptist Church, I agree to abide by and be bound by the policies of Union Chapel Missionary Baptist Church and to refrain from inappropriate conduct in the performance of my duties on behalf of Union Chapel Missionary Baptist Church. I have read this waiver and the entire application, and I am fully aware of its contents. I sign this consent freely and under no duress or coercion. _________________________________________________________________ Signature of Applicant Date _________________________________________________________________ Witness Date FOR OFFICE USE ONLY HIRED ( ) Yes ( ) No POSITION_______________________________________ SALARY/WAGE DATE REPORTING TO WORK______________ APPROVED BY:______________________________________________________________________________________ COMMENTS: This completed application package should be returned to: Union Chapel Missionary Baptist Church 315 Winchester Road Huntsville, Alabama 35811 Attn: Child Development Center Committee NAME/ADDRESS OF HOME/PROVIDER/AGENCY: Union Chapel M B Church Child Development Center 315 Winchester Road Huntsville, AL 35811 MANDATORY CRIMINAL HISTORY CHECK NOTICE: Alabama law requires that a criminal history background information check be conducted on applicants for certain DHR positions and on all persons who hold a license or work in a Department of Human Resources licensed child care or adult care facility, a foster or adoptive home approved by the Department of Human Resources, or a licensed child placing agency, including all officers and agents of the entity. You are required to provide full, complete, and accurate information on your criminal conviction history upon application for a license or employment. This information shall be used to determine your suitability to provide care to children, the elderly, or disabled individuals. Unless a criminal history background information check report and suitability determination have previously been obtained, you must complete a written request and consent for a criminal history background information check with fingerprints at the time of application for employment. Refusal to complete these documents or providing false information shall result in refusal of employment, approval, or licensure. The term conviction includes a determination of guilt by a trial, by a plea of guilty, or a plea of nolo contendere. Any individual determined to have submitted false information shall be referred to the district attorney or law enforcement for investigation and possible prosecution. An individual who intentionally falsifies any information on the statement is guilty of a Class A misdemeanor, punishable by a fine of not more than two thousand dollars ($2,000) and imprisonment for not more than one year. Convictions for any of the following crimes shall make an individual unsuitable for employment, volunteer work, approval, or licensure: Murder, manslaughter, or criminally negligent homicide. A sex crime. A sex crime includes the following: Enticing a child to enter a vehicle, room, house, office, or any other space for immoral purposes, as proscribed by Section 13A669 of the Code of Alabama 1975. Incest, when the offender is an adult and the victim is a minor, as proscribed by Section 13A133 of the Code of Alabama 1975. Kidnapping of a minor, except by a parent in the first or second degree, as proscribed by Section 13A643 or Section 13A644 of the Code of Alabama 1975. Promoting prostitution in the first or second degree, as proscribed by Section 13A12111 or Section 13A12 112 of the Code of Alabama 1975. Rape in the first or second degree, as proscribed by Section 13A661 or Section 13A662 of the Code of Alabama 1975. Sexual misconduct, as proscribed by Section 13A665 of the Code of Alabama 1975. Sexual torture, as proscribed by Section 13A665 of the Code of Alabama 1975. Sexual abuse in the first or second degree, as proscribed by Section 13A666 or Section 13A667 of the Code of Alabama 1975. Sodomy in the first or second degree, as proscribed by Section 13A663 or Section 13A664 of the Code of Alabama 1975. Soliciting a child by computer for the purposes of committing a sexual act and transmittal obscene material to a child by computer as proscribed by Sections 13A61 10 and 13A6111 of the Code of Alabama 1975. Violation of the Alabama Child Pornography Act, as proscribed by Sections 13A12191, 13A12192, 13A12 196, or 13A12197 of the Code of Alabama 1975. Any solicitation, attempt, or conspiracy to commit any of the offenses listed in paragraphs a. to k., inclusive. A crime listed in the Community Notification Act Chapter 20 of Title 15 of the Code of Alabama 1975. A crime that involves the physical or mental injury or maltreatment of a child, the elderly, or an individual with disabilities. A crime committed against a child. A crime involving the sale or distribution of a controlled substance. Robbery. Conviction for a crime listed in the federal Adoption and Safe Families Act for foster and adoptive parents only. Conviction for a violation or attempted violation of an offense committed outside the State of Alabama is a sex crime or any other crime if the offense would be a crime in Alabama. CRIMINAL HISTORY STATEMENT Have you ever had a suitability determination made by the Department of Human Resources in connection with a previous criminal history information background check? Yes (_) No (_). Have you ever been convicted of a crime? Yes (_) No (_). If yes, state the date, crime, location, punishment imposed, and whether the victim was a child or an elderly or disabled individual. ____________________________________________________________________________________________________________________________________________________________________________________________________________ Date _______________________ Signature __________________________________________________________ STATE OF ALABAMA DPS/DHR CRIMINAL HISTORY INFORMATION COUNTY OF MADISON CONSENT AND RELEASE FORM (Please print) My full name is _______________________________________________________________________ I reside at: ____________________________________________________________________________ City of: ____________________________________________ State of: ___________________________ I am possessed of sound mind and am legally competent to execute this consent and release. I hereby give consent and authorize the Alabama Department of Public Safety to release any and all criminal history information on me to the Alabama Department of Human Resources, Personnel Division, Criminal History Checks Unit, P.O. Box 304000, Montgomery, AL 361304000. This report is submitted in connection with the following home/provider/agency: Name and Address (Please print) Union Chapel M. B. Church Child Development Center FOR: ( applicant for license/approval ( employment ( volunteer ( homestudy I do hereby, for myself, my heirs, executors, and administrators, release and forever discharge the Alabama Department of Public Safety and its officers and agents from any and all claims, actions, or causes of action, which may arise as a consequence of the release of the criminal history information. I understand that I will receive a copy of the criminal history report from the Department of Human Resources. I further understand that I have the right to challenge the accuracy of the criminal history report with the Department of Public Safety and have a prompt determination of the validity of that challenge. I certify that I have read this consent and release and that I understand the significance of the same, and in witness thereof I have voluntarily signed my name on this the ___ day of ___________20__. OTHER NAMES/AKAs: SIGNATURE ______________________________________ _______________________________ SS# ______________________________________________ _______________________________ DATE OF BIRTH _____________ RACE_______ SEX ________ ___________________________________________ Witness Sworn to and subscribed before me on this the ___________________________________________ ______ day of __________________ 20___. Address ___________________________________________ City State Zip ___________________________________________ ___________________________________ Witness NOTARY PUBLIC ___________________________________________ Address ___________________________________________ City State Zip My commission expires _________________ PLEASE NOTE: This document must be witnessed by two (2) witnesses or notarized by a Notary Public. SEND MONEY ORDER OR CASHIER'S ALABAMA BUREAU OF INVESTIGATION CHECK OR CERTIFIED CHECK PAYABLE TO: IDENTIFICATION UNIT P.O. BOX 15 11 MAIL FORM AND FINGERPRINT CARDS TO: MONTGOMERY, AL 361021511 SEND COPY OF FORM ONLY TO: ALABAMA DEPT OF HUMAN RESOURCES PERSONNEL DIVISION CRIMINAL HISTORY CHECKS UNIT P.O. 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