Welcome!
We are so excited that you have expressed interest in becoming a part of our child care team! We are always looking for
qualified individuals who are ready to jump on board at KidTowne. We offer flexible hours of employment to our
customers as well as to our employees. Employment at KidTowne is an exciting as well as an enriching experience. If you
love children and are ready to play a significant role in their lives, please provide the following information!
I. Personal Information
Contact Information
Name:
Street Address:
City:
Phone:
State:
Cell:
Desired Position (circle all that apply): Lead Teacher
Zip Code:
Email:
Assistant Teacher
Floater
Date You Can Start: ___________________
Are you interested in full time or part time hours? _________
Have you ever been convicted of a felony and / or a misdemeanor? ________
If yes, please explain: ________________________________________________________________________________
__________________________________________________________________________________________________
II. Employment History
Please enter information for your three most recent employers
Current/most recent employer
Employer name:
Location:
Position:
Reference name:
May we contact?
Reason for leaving:
Dates of employment:
From:
To:
Reference contact info:
Previous employer 1
Employer name:
Location:
Position:
Reference name:
May we contact?
Reason for leaving:
Dates of employment:
From:
To:
Reference contact info:
Previous employer 2
Employer name:
Location:
Position:
Reference name:
May we contact?
Reason for leaving:
Dates of employment:
From:
To:
Reference contact info:
III. Education
High School
High School Name:
Years Attended
From:
Address
Street:
City:
Special studies:
College
College Name:
Years Attended
Address
Degree/studies:
From:
Street:
City:
To:
Graduated Y N GED
State:
To:
Zip:
Graduated Y N
State:
Zip:
Other
Years Attended
Address
From:
Street:
City:
Degree/certificate/studies:
To:
State:
Zip:
IV. Multiple Languages, Areas of Special Study, Applicable Experience or Talents
Languages Spoken and/or Written:
Special Areas of Study/Research:
Other Applicable Experience, skills or talents:
V. References
Please provide 3 professional references. Please, no friend or family references. List one former employer.
Reference 1
Name:
Address:
Relationship:
Phone:
Email:
Reference 2
Name:
Address:
Relationship:
Phone:
Email:
Reference 3
Name:
Address:
Relationship:
Phone:
Email:
VI. Availability
We employ both regularly scheduled teachers and on-call teachers. Please indicate your availability and interest in these
two types of positions in the tables below.
Please mark all times you are available and interested in working regularly in the table below:
Day
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Early AM (6-9) M-F
Morning (9-12)M-Sa
Afternoon (12-6)
Evening (6-10) M-Su
Evening(10-12)Fr-Sa
Please mark all times you are available and interested in being on call in the table below:
Day
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Early AM (6-9) M-F
Morning (9-12)M-Sa
Afternoon (12-6)
Evening (6-10) M-Su
Evening(10-12)Fr-Sa
VII. Age group interests
Please mark your interest level in working with each of the following age groups and programs:
Highly interested
Infants (0-18 months)
Toddlers (18-30 months)
Preschool program (2.5-4 years)
School age (5-12 years)
Interested
Less interested
VIII.
Certifications and Signature
I CERTIFY that the facts presented in this application are true and complete to the best of my knowledge.
In the event of employment, I UNDERSTAND that should any statements made in this application or during the interview
process prove to be false, that this may be grounds for immediate dismissal.
I UNDERSTAND that there is no stated or implied minimum length of employment and that should I be hired, I agree that
my employment may be terminated at any time, without prior notice, or just cause.
I UNDERSTAND that all common areas within KidTowne are under video surveillance at all times. These recordings may
be used in the investigation of employees.
I UNDERSTAND that all claims and disputes arising under or relating to this Agreement are to be settled by binding
arbitration in the state of Alabama or another location mutually agreeable to the parties. An award of arbitration may be
confirmed in a court of competent jurisdiction.
I AUTHORIZE KidTowne to investigate all statements made in this application and to contact any references given, while
releasing KidTowne from any liabilities and/or damage caused.
I certify that I am legally entitled to work in the United States and that all permits are currently valid.
Signed: ________
Date:
Administration use only:
Signature of Director: ___________________________ __ Date Hired: _______________________________
Position Awarded: _____________________________________
KidTowne is an Equal Opportunity Employer. Applications are considered without regard to race, color, religion, sex,
national origin, age, marital or veteran status, or the presence of a non-job related medical condition or handicap.
Employee File Checklist
*The following items must be on file before employment will be fully enacted:
_____ Application (fill out online and submit)
_____ Three Reference Letters (sent from KidTowne to references provided by applicant)
_____ Physician Release Form (included-print, obtain physician clearance, and return)
_____ Minimum Standards Verification Form (included-print and return)
(for standards, go to: http://dhr.alabama.gov/documents/MinimumStandards_DayCare.pdf)
_____ Copy of current Driver’s License
_____ Copy of Social Security Card
_____ CPR/First Aid Certificate
_____ Certificates Verifying 12 Training Clock Hours in Child Care (within 30 days of employment)
_____ High School or College Transcript
_____ A copy of the Criminal History Information Consent and Release Form. (complete online- print and return)
(go to: http://dps.alabama.gov/Documents/Forms/ABI-CriminalHistoriesGeneralPublic-46.pdf)
_____ A copy of the Mandatory Criminal History Check Notice. (from DHR)
_____ Request for Clearance of State Central Registry on Child Abuse/Neglect (complete and submit online)
(go to: http://dhr.alabama.gov/services/Child_Protective_Services/form1598.pdf)
_____ A Suitability Determination letter from the Department. (from ABI and FBI)
MEDICAL REPORT FOR PERSONS GIVING CARE TO CHILDREN
Name:
Date of birth:
Address:
Position in child care facility:
To the examining medical doctor, physician's assistant, or certified nurse practitioner:
This examination is needed to determine my physical ability to care for children or
to perform services in a child care facility (home or center) or to have contact with children
in care. I hereby authorize you to furnish a report of my examination to:
_____________________________________________________________________
Name of child care facility or Department of Human Resources
_______________________________________________________/___________
Signature
Date
___________________________________________________________________________
TESTS (to be completed if other verification is not attached):
Date and result of Intradermal Tuberculin Test (Mantoux): __________________
(Required for initial examination only)
Date and result of chest x-ray if Mantoux was positive: ____________________
HISTORY of any chronic disease or disability that may affect his/her ability to care for children
or perform services in a child care facility: Yes _; No _.
PHYSICAL LIMITATIONS that may affect his/her ability to care for children or perform
services in a child care facility (home or center): Yes _; No _.
If "YES", to either question, please explain:
______________________________________________________________________________
______________________________________________________________________________
In my opinion, the physical examination reveals that the above-named person is free of any
infectious or contagious disease and is physically fit to care for children, to perform services in a
child care facility, or to have contact with children.
If not, please explain:
______________________________________________________________________________
______________________________________________________________________________
________________________________________________________________/__________
Signature of medical doctor, physician's assistant, or certified nurse practitioner / Date
VERIFICATION THAT STAFF PERSONS HAVE READ THE
MINIMUM STANDARDS
Written and signed verification stating that staff persons have read the Minimum
Standards within one month of employment, must be in each staff person's file in the
center.
I have read the Minimum Standards for Day Care Centers and Nighttime Centers. I
understand that I must comply with these regulations while I am employed at
______________________________________________
(Name of center)
Failure to do so could result in immediate termination of employment.
__________________________________________
Signature of staff person Date
_________________________________________
Signature of Licensee/Director Date