Goldie B. Floberg Center Employment Application
Goldie B. Floberg Center for Children
58 W. Rockton Road
Rockton, IL 61072
Phone: 815-624-8431
Fax:815-624-8461
Email address *
Today's Date *
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Applicant Info
First Name *
Your answer
Middle Name
Your answer
Last Name *
Your answer
List other names used
Your answer
Current Mailing Address (street address) *
Your answer
Current Mailing address (city, state, zip) *
Your answer
Phone Number *
Your answer
Date of birth: 00/00/0000 (DCFS and DHS have a minimum age requirement to work as a DSP in our programs) *
Your answer
How did you hear about us? *
If you were referred by a staff member please note who referred you: (or who posted it on Facebook)
Your answer
Date available for work: *
Your answer
What position are you applying for? *
Required
Have you ever applied with our agency before? If so please say when. *
Your answer
Desired employment status? (We have openings for all status types) *
Are you legally eligible to work in the United States? *
Have you ever been named in a child abuse, neglect or mistreatment complaint or investigation? *
Have you ever been granted a waiver by the DCFS, DHS, or other agency to work in the human services field? *
Have you ever been convicted of a crime? *
If you answered yes to the previous question please explain below.
Your answer
Have you ever been convicted of DUI, driving while impaired, driving while intoxicated or any similar offenses relating to drugs/alcohol? *
It is an essential function of the Direct Support Professional position to have the ability to lift a minimum of 50 lbs or more, and exert up to 100 lbs of force. Are you able to meet these requirements? *
Education
Please name the school you attended and if/when you graduated.
High School *
Your answer
Diploma *
Required
College(s) (Include major & minor if you completed your degree)
Your answer
Degree Completed
Other
Your answer
Special Courses: Please list any additional training that you may have received, including military training, apprenticeship programs, vocational training, courses and/or seminars.
Your answer
Experience (if any) working with people with developmental disabilities?
Your answer
Employment History/ Work References
Employment History 1 (Please list name of employer, start & end dates, salary, position, and reason for leaving.) *
Your answer
Work Reference 1: (Please list Employer name and phone number for job listed above) *
Your answer
Employment History 2 (Please list name of employer, start & end dates, salary, position, and reason for leaving.)
Your answer
Work Reference 2: (Please list Employer name and phone number for job listed above) *
Your answer
Employment History 3 (Please list name of employer, start & end dates, salary, position, and reason for leaving.)
Your answer
Work Reference 3: (Please list Employer name and phone number for job listed above)
Your answer
Employment History 4 (Please list name of employer, start & end dates, salary, position, and reason for leaving.)
Your answer
Work Reference 4: (Please list Employer name and phone number for job listed above)
Your answer
Personal References
Please list first AND last name, relationship and phone number. NO RELATIVES
Personal Reference 1: (Please list first AND last name, relationship and phone number. NO RELATIVES) *
Your answer
Personal Reference 2: (Please list first AND last name, relationship and phone number. NO RELATIVES) *
Your answer
Personal Reference 3: (Please list first AND last name, relationship and phone number. NO RELATIVES) *
Your answer
Personal Reference 4: (Please list first AND last name, relationship and phone number. NO RELATIVES) *
Your answer
Our Values, Our Culture, Your Career.
At the Goldie B. Floberg Center our culture and very essence has been carefully crafted around our values. We look for motivated individuals that value what we value and strive to implement these values in everything that they do. As part of our employment consideration process all applicants are asked to provide an example of how they live or exemplify the following values in his/her own life or how they would strive to do this if employed by the Goldie B. Floberg Center. Examples must be descriptive but should not include identifying or private information.
Being an Amazer: We value the happiness, excitement and sense of well being we create when we amaze and delight every person we interact with. We value people who love to amaze the people we serve, their families, each other, our supporters and our community. Please give example below:
Your answer
Teamwork: We value being able to communicate openly and honestly with on another. We value helping each other to implement our mission regardless of what our role in the agency is. We value working hard and having fun together. Please give your example below:
Your answer
Integrity: We value being honest in all that we do. We value acting the same at all times no matter who is watching. We value being accountable to those we serve and to each other. Please give your example below:
Your answer
Leadership: We value those who lead by example. We value leaders who build people up instead of breaking them down. We value leaders who can inspire people to make our mission a reality. We value leaders who model our values. Please give your example below:
Your answer
Growth: We value growth of our agency through innovation and developing services of value to the people we serve. We value personal growth through rising to new challenges, a perpetual drive to improve, and life-long learning. Please give your example below:
Your answer
Fun: We value making each other laugh. We value playfulness, silliness, geekiness, and goofiness. We value people who bring joy to those around them. We value people who know what working hard and having fun go hand in hand if we are going to be successful in helping people build lives of enrichment and empowerment.
Your answer
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