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Staff Application

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Glen Rose Christian Co-op

Application for Team Member

Personal Information
1. *

First Name
2. *

Last Name
3. 

Preferred Name
4. *

Gender 
Male Female
5. *

Cell Phone 
6. *

Date of Birth
7. *

Full Address, City, State, Zip
8. *

Email Address
9. 

Home Church, if any
10. *

If you have a home church, how involved are you?
Very Somewhat
Not Very N/A
11. *

Are you striving daily to follow Christ?
Yes No
12. *

Have you been baptized?
Yes No

Teaching Information & Preferences
13. *

Are you available on Tuesdays between 12:45-4:00?
Yes No
14. 

If no, please specify the times you are available during those hours. 
15. *

Classes are typically 55 minutes long. How many classes are you interested in teaching? 
1 2
3

Class Preference #1
16. 

What class/subject would you like to teach?
17. *

What ages/grades?
18. *

Anticipated monthly fee?
19. *

One-time supply fee?

Class Preference #2
20. 

What class/subject would you like to teach?
21. 

What ages/grades?
22. 

Anticipated monthly fee?
23. 

One-time supply fee?

Class Peference #3
24. 

What class/subject would you like to teach?
25. 

What ages/grades?
26. 

Anticipated monthly fee?
27. 

One-time supply fee?

Educational and Professional Training

Credential #1
28. *

Organization (if applicable)
29. 

School/Organization 
30. 

Dates of Attendance (Years)
31. 

Degree or Certificates Earned

Credential #2
32. 

School/Organization
33. 

Dates of Attendance (Years)
34. 

Degree or Certificates Earned

Credential #3
35. 

School/Organization
36. 

Dates of Attendance (Years)
37. 

Degree or Certificates Earned

Relevant Employment History

Position #1
38. *

School Name & Location
39. *

Position/Grade/Subject Taught
40. *

Dates Employed
41. *

Employment Type
Full Time Part Time
42. 

Reason For Leaving
43. *

Supervisor or Contact Name
44. *

Contact Phone Number 

Position #2
45. 

School Name & Location
46. 

Position/Grade/Subject Taught
47. 

Dates Employed
48. *

Employment Type
Full Time Part Time
N/A
49. 

Reason For Leaving
50. 

Supervisor or Contact Name
51. 

Contact Phone Number 

Position #3
52. 

School Name & Location
53. 

Position/Grade/Subject Taught
54. 

Dates Employed
55. *

Employment Type
Full Time Part Time
N/A
56. 

Reason For Leaving
57. 

Supervisor or Contact Name
58. 

Contact Phone Number 

Medical Information
59. *

Date of last tetanus shot?
60. *

Known Allergies?
61. *

Reaction to allergies?
62. *

Doctor's name 
63. *

Doctor's Phone Number
64. *

Insurance Carrier
65. *

Policy Number 
66. *

Insurance Phone Number

Emergency Contact Info

In case of an emergency, please contact: 
67. *

Name
68. *

Phone Number
69. *

Relationship
70. *

Street Address, City, State

Professional & Personal References

Referrence #1 - Church or Community Leader
71. *

Name
72. *

Organization
73. *

City & State
74. *

Position/Title
75. *

Phone Number 

Reference #2- Professional Reference
76. *

Name
77. *

Organization
78. *

City & State
79. *

Position/Title
80. *

Phone Number 

Reference #3- Additional Reference
81. *

Name
82. *

City & State
83. *

Relationship/Title 
84. *

Phone Number 

Essay/Short Answer
85. *

What do you feel is your greatest strength/asset that will help you as a staff member?
86. *

What do you feel is your greatest area of weakness or an area you would like to improve?
87. *

Briefly describe how you might handle a situation in which you have a student that is being disrespecful or disobedient in class. 
88. *

How do you believe one can be confident that they are going to heaven?
89. *

In a few sentences, please explain your views on the following cultural topics: marriage, gender identity, homosexuality, and LBGTQ issues. 

Applicant Acknowledgment & Authorization

Please review and respond to the following statements. Your digital signature indicates that the information provided is accurate and complete. 
90. *

Have you read and do you agree to abide by the Parent and Teacher handbook? 

 (1 required)
Yes No
91. *

Have you ever been accused of or convicted of a crime involving a child?

 (1 required)
Yes No
92. *

If yes, please provide an explanation.
93. *

Are you willing to provide additional information if needed to complete a background check?

 (1 required)
Yes No
94. *

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any false or misleading information may result in disqualification or dismissal. 
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
95. *

Date
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