Hearts & Minds Employment Application
Please complete entire application.

It is the policy of Hearts & Minds Early Childhood Program to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status.
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Email *
Applicant Information
Please fill out each section completely.
Applicant full name: *
Home Address: *
Daytime/Evening phone number: *
Emergency Contact
Please fill out section completely.
Emergency contact name & phone number: *
Emergency contact address: *
Employment Questions
Please fill out the section completely.
Job position you are applying for: *
Which days of the week, would you be available to work?  *
Required
All of our positions are considered part-time.  How many days of the week are you looking to work? *
Required
What is your desired salary? *
Who referred you to our company? *
Do you have any friends or relatives who work here? if yes please list here. *
Are you at least 18 years of age *
How will you get to work? *
If you are offered employment, when would you be available to begin work? *
If hired, are you able to submit proof that you are legally eligible for employment in the United States? *
Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation? *
If you need accommodation what reasonable accommodation, if any, would you request? *
Have you ever been convicted of a felony or misdemeanor? *
If you answered yes to the above questions please list what the felony or misdemeanor you were convicted of, the date, city and state. *
 **The existence of a criminal record does not constitute an automatic bar to employment unless relevant to the type of employment.**
Applicant's Skills
Please fill out this section completely.
What are your skills, and strengths? What areas would you like to learn and grow in? *
Applicant Employment History
List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held. Please list and explain any gaps in employment.
1. Employer name, Supervisor name: *
Address including City/State/Zip code. *
Job duties performed: *
Dates of employment and reason for leaving: *
2. Employer name, Supervisor name: *
Address including City/State/Zip code. *
Job duties performed. *
Dates of employment and reason for leaving. *
3. Employer name, Supervisor name. *
Address including City/State/Zip code. *
Job duties performed. *
Dates of employment and reason for leaving. *
Education & Training
Please fill out this section completely.
College/University name and address: *
Did you receive a degree? *
If you answered yes to the above answer, what degree(s) where received? *
Other training (graduate, technical, vocational): *
Please indicate any current professional Licenses or certifications that you hold: *
Please list any awards, honors or special achievements that you received: *
References
Please list any two non-relatives who would be willing to provide a reference for you.
1. List name and relationship *
List phone number and email address *
2. List name and relationship: *
List phone number and email address:  *
We offer free childcare during after hours trainings and meetings.  Feel free to list children and their ages below, who might utilize this care.  
Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer: *
Certification
I certify that the information provided on the application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize Hearts & Minds Early Childhood Program to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated at references to fully and freely communicate information regarding my previous employment and education.

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by it's Director, the employment relationship will be "at-will." In other words, the relationship will by entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Hearts & Minds Early Childhood Program, except in a specific written contract of employment signed on behalf of the organization by its Director, has the power to alter or vary the voluntary nature of the employment relationship.
I have carefully read the above certification and I understand and agree to its terms.  (please type your first & last name along with the date.) *
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