Date of Application

Applicant Signature 

By signing below & submitting this application, I certify that the information I provided is accurate and understand that providing false information is grounds for immediate termination, if hired. I give my permission for the references listed to be contacted to verify the information given, and provide their opinion on my availability to preform the job duties of the position I am applying for at Children's Imagination Station.

Relationship

Phone

Address

Name

Relationship

Phone

Address

Name

Relationship

Phone

Address

Name

References 

Training & Skills (Ex: Babysitting Clinic, First Aid Certified, Great decision Making, etc.)

School(s) Attended

Highest Level of Education

List Past Education & Training

Past Job Duties (Please list as many day-to-day tasks as you can)

Job title

Reason For Leaving

May We Contact Them?

Hourly Wage

Dates of Employment

Name of SupervisoR

Phone

Address

Employer #2

Past Job Duties (Please list as many day-to-day tasks as you can)

Job title

Reason For Leaving

May We Contact Them?

Hourly Wage

Dates of Employment

Name of SupervisoR

Address

Phone

Employer #1

List Past Employment History

Are you 18 or older?

Email:

Alternative Phone:

Your Address:

Phone:

name:

Caregiver