Application for Employment
Tippecanoe County Child Care, Inc.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER
We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or other legally protected status.

Last Name

First Name

Middle Initial

Address

City

State

Zip Code

Telephone Number(s)	E-mail Address

Position(s) Applying For:	Date of Application

If Classroom Position, Age Group Preference(s) (If Any)

No Preference	Infants / Toddlers	Two's / Three's	Preschool
Multi-Age	School-Age

Location Preference(s) (If Any)

No Preference	Administration	Dennis Burton Center	Downtown Center
Tippy East Center	Sunrise Center	Wabash Landing Center	After School - Miller
After School - Earhart	The Child Care Resource Network

Would you prefer:	No Preference	Full Time	Part Time
Have you ever filed an application with us before?		Yes	No
If yes, give date and last name on application, if different.		Date	Last Name
Have you ever been employed with us before?		Yes	No
If yes, give dates and last name, if different.		Date	Last Name
On what date would you be available for work?
Are you legally authorized to work in the United States?		Yes	No
Have you ever been convicted of a crime other than a minor traffic incident?		Yes	No
If yes, please explain.

EDUCATION

	Name and Address of Institution	Major/Course of Study	Dates Attended		Degree/Diploma Obtained
	Name and Address of Institution	Major/Course of Study	From	To	Degree/Diploma Obtained

High School
College
Graduate
Other (Please Specify)

*Unless in a job training program, classroom staff must be at least 18 years old and have a High School Diploma or GED.

Describe any relevant specialized training, apprenticeship, qualifications and/or skills.

Employer 1	Dates employed	Job Duties
	From To
Telephone Number(s)	Final Hourly Rate/Salary


Reason for Leaving
	May we contact? Yes No

Employer 2	Dates employed	Job Duties
	From To
Telephone Number(s)	Final Hourly Rate/Salary


Reason for Leaving
	May we contact? Yes No

ACTIVITIES AND OFFICES

List professional, trade, business, or civic activities and offices held. You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability, or other protected status.

REFERENCES

Name	Job Title	Telephone Number(s)

Address	City	State	Zip Code


Name	Job Title	Telephone Number(s)

Address	City	State	Zip Code

PERMISSION TO CONTACT

I give Tippecanoe County Child Care, Inc., permission to contact the references listed above.

For employers listed on the pervious page, I likewise give permission for Tippecanoe County Child Care, Inc., to contact only those for whom I have answered "yes" or in the affirmative to the question, "May we contact?"


Signature of Applicant	Date

EMERGENCY INFORMATION

In the event of an emergency, notify one or both of the following people:

Name	Relationship	Phone

Name	Relationship	Phone

APPLICANT'S STATEMENT

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed six (6) months. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.


Signature of Applicant	Date

Tippecanoe County Child Care, Inc. is a private non-profit United Way Agency. Our mission is to provide and teach the best practices in early childhood care and education in an inclusive environment, which embraces the development of each individual child.

Applicant Self-Identification Form

Tippecanoe County Child Care is an Equal Opportunity/Affirmative Action Employer and complies with all federal and state regulations. We are required to solicit the information indicated below. This information is kept for statistical reporting and federal EEO/AA requirements. Your responses are voluntary and your cooperation in providing this information is appreciated.

Position Applied for:
Department/Division:
Applicant's Name:
Gender	Male	Female
Race/Ethnicity: Please choose the category that best describes you.
Native American / Alaskan Native A person having origins in any or the original peoples of North America and maintains cultural identification through tribal affiliation or community recognition.
White (not of Hispanic origin) A person having origins in any of the original people of Europe, North Africa, or the middle East.
Black / African American (not of Hispanic origin) A person having origins in any of the black racial groups of Africa.
Asian / Pacific Islander A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes China, Japan, Korea, Vietnam, Cambodia, the Philippine Islands and Samoa.
Hispanic / Latino Mexican, Puerto Rican, Central / South American, or other Spanish culture of origin, regardless of race.
Multiracial A person having a biological parent whom is different race from their other biological parent.

FOR OUR INFORMATION

How did you hear about available positions?	NA
Journal and Courier	TV	Proud	Website
Ivy	Tech Employee	Other (Please specify)	_______________________________
How did you hear about the Agency?
Journal and Courier	TV	Purdue	Yellow Pages
Ivy	Tech Employee	Other (Please specify)	_______________________________

Application for Employment Tippecanoe County Child Care, Inc.