EMPLOYMENT – Kids Learning Zone

Name *

First

Last

Email *

Phone *

Appointment Date

Date

Time

Address

Address Line 1

Address Line 2

City

State

Zip Code

Position for which you are applying *

Citizenship *

Date of Birth

Emergency Contact Information

Name *

First

Last

Relationship

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Please answer the following questions

Have you ever held a child care license with the Department of Children and Families or been registered to provide child care in your home? *

Yes
No

While employed in a child care program, have you ever been the subject of disciplinary action, or been the part responsible for a child care facility receiving an administrative fine or other disciplinary action? *

Yes
No

If yes, please explain

BACKGROUND SCREENING & PERSONNEL FILE REQUIREMENTS

Postion Classification

Child Care Personnel
Intermittent Volunteer
Other Personnel

Position Type (check all that apply)

Age Group Assigned

Education Level

Screening Documentation

All child care personnel are required by law to be screend pursuant to Chapter 435, F.S., as a condition of employment and continued employment. Screening must be completed prior to employment, following a 90 day breakin service, and every five years.

FBI/FDLE/Florida Sex Offender/National Sex Offender/Out of state criminal records (if applicable)

Date LiveScanned

Date Eligible

Retention Date

Florida Child Abuse Registry Check (if screening was processed between July 1, 2016 and December 15, 2016)

Date Email Notification Received

Attestation of Good Moral Character (due on or before employment, following a 90 day break, or when changing employers)

Date Signed

Out of State Criminal History Check (if applicable)

Date Request Submitted

Date Results Received

Out of State Abuse and Neglect Registry (if applicable)

Date Request Submitted

Date Results Received

Out of State Sex Offender Registry Check (if applicable)

Date Request Submitted

Date Results Received

5 Year Re-screen

FBI/FDLE/Florida Sex Offender/National Sex Offender/Out of state criminal records (if applicable)

Date LiveScanned

Date Eligible

Retention Date

FBI/FDLE/Florida Sex Offender/National Sex Offender/Out of state criminal records (if applicable)

Date LiveScanned

Date Eligible

Retention Date

Date 5 Year Employment Reference Checks Completed

Resume Upload *

Click or drag a file to this area to upload.

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