Employment Application

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STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY

PERSONNEL RECORD
(form to be completed by employee)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

Name of Facility
Extended Child Care

Facility Address
1745 Copperhill Parkway, Suite 5
Santa Rosa, CA 95403

Facility File Number
490107325

* Indicates required field

Date *

PERSONAL

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Are you 18 years old or older *

Yes No

If no, please state your age *

Date of last physical examination *

Date of last TB test *

Have you ever been employed under a different name *

Yes No

If yes, please list all names used *

Name of nearest living relative *

Relationship *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Do you posses a valid California drivers license *

Yes No

CDL Number *

Has your license ever been suspended or revoked *

Yes No

If yes, please explain *

PROFESSIONAL

Are you currently employed *

Yes No

Name of Employer *

Name of Supervisor *

Title/Position *

Date of Employment *

Salary *

Hours *

Previous Employment

Name of Employer *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Dates Employed (start date & end date) *

Reason for leaving *

Name of Employer *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Dates Employed (start date & end date) *

Reason for leaving *

Name of Employer *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Dates Employed (start date & end date) *

Reason for leaving *

EDUCATION

Check highest year completed *

6 7 8 9 10 11 12

Diploma *

Yes No

Currently enrolled in a high school completion course *

Yes No

If yes, please give expected completion date *

Employment Related Education Courses

Course Title *

Name of institution *

Number of Units *

Date completed *

Currently enrolled *

Course Title *

Name of institution *

Number of Units *

Date completed *

Currently enrolled *

Course Title *

Name of institution *

Number of Units *

Date completed *

Currently enrolled *

Course Title *

Name of institution *

Number of Units *

Date completed *

Currently enrolled *

University, College or Business School

Name of Institution *

Major Subject *

No. years completed *

No. of units completed *

Diploma, Degree, Certificate *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date Completed *

Name of Institution *

Major Subject *

No. years completed *

No. of units completed *

Diploma, Degree, Certificate *

Date Completed *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Name of Institution *

Major Subject *

No. years completed *

No. of units completed *

Diploma, Degree, Certificate *

Date Completed *

Address *

Line 1

Line 2

City

State

Zip Code

Country

REFERENCES
(please list names of 3 persons who can give information about your background, character, abilities, etc.)

Name *

First

Last

Relationship to you (friend, family, teacher, employer, etc.) *

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Name *

First

Last

Relationship to you (friend, family, teacher, employer, etc.) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Name *

First

Last

Relationship to you (friend, family, teacher, employer, etc.) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

PROFESSIONAL & TECHNICAL QUALIFICATIONS

List licenses, Certificates and/or Competencies held *

Name of Professional Associations of which you are a member *

I hereby certify under penalty of perjury that the above statements are true and correct. I give my permission for any necessary verification.

Signature *

Date *

Extended Child Care
Questionnaire for Prospective Employees

What is your experience working with school aged children? What age groups are you comfortable with? *

Have you ever worked in a child care center? If so, please describe *

Describe your strong points in working with children. *

What are your employment goals with Extended Child Care? (i.e. full time, part time, school year, and summer) *

What would you be able to offer in school age curriculum? (i.e. projects, outside sports, group games, homework assistance) *

Do you have College Level Child Development units? If so, how many? Copies of transcripts will be needed for employment *

When are you available to work? Please indicate the days and hours you are available. We are open for morning shifts (7am-9am) and afternoon shifts (1pm-6pm) during the School Year and we are open 7am-6pm during the summer. *

What languages do you fluently speak? *

How did you hear about us? *

RESUME
Please upload a copy of your resume below.

Upload File *

Max file size: 50MB

Upon submission of this application, we will email you a Criminal Record Statement document and instructions. This document will be require for your application for employment to be considered complete. Thank you for your interest in working for Extended Child Care.

Submit

Donate

PERSONNEL RECORD(form to be completed by employee)​

PERSONAL

PROFESSIONAL

​

Previous Employment

EDUCATION

Employment Related Education Courses

University, College or Business School

REFERENCES(please list names of 3 persons who can give information about your background, character, abilities, etc.)

PROFESSIONAL & TECHNICAL QUALIFICATIONS

Extended Child CareQuestionnaire for Prospective Employees

RESUMEPlease upload a copy of your resume below.

This institution is an equal opportunity provider.

PERSONNEL RECORD
(form to be completed by employee)

REFERENCES
(please list names of 3 persons who can give information about your background, character, abilities, etc.)

Extended Child Care
Questionnaire for Prospective Employees

RESUME
Please upload a copy of your resume below.