Latchkey Child Services: Where Students Get to Be Kids

Personal Information

Name*

First Middle Last

Social Security Number*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Referred By

Employment Desired

Position Desired

Desired Start Date

Salary Desired

Are you currently employed?*

Yes

No

May we contact your present employer?*

Yes

No

Have you applied to Latchkey before?*

Yes

No

Education

High School

Years Attended

Did you graduate?

Yes

No

College

Years Attended

Did you graduate?

Yes

No

Subjects Studied

Other

Years Attended

Did you graduate?

Yes

No

Subjects Studied

Subjects of Special Study or Special Training/Skills

Employment History

Employer

From

To

Address

Street Address Address Line 2 City State ZIP Code

Phone

Salary

Position

Reason For Leaving

Employer

From

To

Address

Street Address Address Line 2 City State ZIP Code

Phone

Salary

Position

Reason For Leaving

Employer

From

To

Address

Street Address Address Line 2 City State ZIP Code

Phone

Salary

Position

Reason For Leaving

References

Name

Title or Position

Address

Street Address Address Line 2 City State ZIP Code

Phone

Business or Personal

Business

Personal

Name

Title or Position

Address

Street Address Address Line 2 City State ZIP Code

Phone

Business or Personal

Business

Personal

Name

Title or Position

Address

Street Address Address Line 2 City State ZIP Code

Phone

Business or Personal

Business

Personal

Miscellaneous Information

Additional information you feel is pertinent:

Do you have any medical, physical, emotional conditions or personal conflicts that would prevent you from performing daily routine duties of supervising children ages 3 to 14? Duties include, but are not limited to walking, running, standing, sitting, reading, writing and lifting (not to exceed 40 lbs.):*

Yes

No

Please Describe In Detail*

Have you ever been convicted of or entered a plea of guilty or nolo contendere (no contest) to any criminal activity involving violence against a person; child abuse or neglect; possession, sale or distribution of illegal drugs; sexual misconduct; gross irresponsibility or disregard for the safety of others?*

Yes

No

If yes, please attach additional information with the submittal of this application form.*

Accepted file types: pdf, Max. file size: 100 MB.

Authorization

I hereby certify that this information is true and complete to the best of my knowledge. I also authorize a complete background check, including verification of education and employment, reference check and criminal background check. If hired, any falsification of information herein or on this application form can result in immediate dismissal.

Date*

Background Signature*

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.”

Date*

Email*

Signature*

CAPTCHA

Application Form

Personal Information

Employment Desired

Education

Employment History

References

Miscellaneous Information

Authorization

Latchkey Child Services Inc.