Received____________ Contacted__________ Interviewed________
APPLICATION FOR STUDENT EMPLOYMENT
MUST BE A STUDENT
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital status, veteran status, sexual orientation, or any other legally protected status.
(PLEASE PRINT)
Last Name
Address
Telephone Number(s)
Email Address
|
First Name M.I.
City State
|
Zip Code
|
Cell Phone Number
Have you ever been employed with us before? Yes No
If yes, give dates and last name:
Are you prevented from lawfully becoming employed in this country because of visa or immigration status?
Yes No (Proof of citizenship or immigration status will be required upon employment)
Have you been convicted of a felony within the last 7 years? _____ Yes ______ No
(Conviction will not necessarily disqualify an applicant from employment.)
If yes, please explain: ___________________________________________
All employees of MCDLS must consent to a drug test, and have a TB test within the past year. I understand and agree_________/____________ (initial –date)
A Criminal History Check will be completed by Purdue University.
EDUCATION
Name & Address of School Course
of Study
Years
Completed
Diploma
Degree
High School
Undergraduate
College
Graduate
Professional
Other
(Specify)
Describe any relevant specialized training, qualifications, and/or skills:

EMPLOYMENT EXPERIENCE
Start with your most recent job. Include any job-related military service assignments and volunteer activities. You may exclude any organization which indicates race, color, religion, gender, national origin, disabilities, or other protected status.
Employer Dates Employed Work Performed
Address
Telephone Number
Reason for leaving
Supervisor
May we contact?
Job Title
Employer
Address
Telephone Number
Reason for leaving
Dates Employed
Supervisor
May we contact?
Work Performed
Job Title
PROFESSIONAL REFERENCES*
Please list three people, not related to you, who can comment on your potential as an employee of MCDLS.
Name Job Title Telephone Number
Address City State Zip Code
Name Job Title Telephone Number
Address City State Zip Code
Name Job Title Telephone Number
Address City State Zip Code
PERMISSION TO CONTACT
I give MCDLS permission to contact the references listed above. For employers listed in the
Employment Experience section, I also give permission for MCDLS to contact only those for whom I have answered “yes” or in the affirmative to the question: “May we contact?”
Signature of Applicant Date

APPLICANT’S STATEMENT
I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all policies, rules, and regulations of the employer.
I understand that in order to work at MCDLS I must have a current clear TB test (within 3 months of my first day at MCDLS and yearly thereafter). I also understand that all employees must attend orientation prior to beginning work. I understand I must be in student status to apply for a student worker position.
Signature of Applicant Date
Please Mark in Pencil :
In the space provided below, please indicate, by placing an X in the box, the times during each day of the week that you are not available to work.
Name: Phone:
TIMES
7:30 – 8:20 a.m.
8:30 – 9:20 a.m.
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
9:30 – 10:20 a.m.
10:30 – 11:20 a.m.
11:30 – 12:20 p.m
12:30 – 1:20 p.m.
1:30 – 2:20 p.m.
2:30 – 3:20 p.m.
3:30 – 4:20 p.m.
4:30 – 5:20 p.m.

Please briefly answer the following questions
1.
What is your experience caring for or interacting with children between the ages of 6 weeks and 5 years of age? Describe work, volunteer, church, community or family experiences you have working with children.
2.
What are the things you have especially enjoyed doing while caring for/ interacting with children?
3.
Briefly explain your views on child guidance and discipline.
4.
Why do you want to work at MCDLS?