Suffolk Public Schools by G915K4

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									                                            Suffolk Public Schools
                                                     P.O. Box 1549
                                                   Suffolk, VA 23439
                    APPLICATION FOR 2012 ELEMENTARY SUMMER SCHOOL
                                   June 27 – July 26, 2012

Please check one:              □Teacher            □Nurse               □Teacher Assistant (office assistant)
NAME________________________________________________________ ID#______________________________

ADDRESS______________________________________________________________________________________
                      Number & Street                            City                 State                 Zip

TELEPHONE_____________________________________________________________________


CERTIFICATE:
*Do you have a Virginia Teacher’s Certificate? __________Yes __________No
If yes, what grades and/or subject area(s) are you endorsed to teach? (list)
________________________________________________________________________________________________

*Do you have a Teacher’s Certificate from a state other than Virginia? _______Yes _______No

EXPERIENCE:

Current Teaching Position:
_________________________      _____________________         ___________________________           _________________________________
SCHOOL ASSIGNMENT              SUBJECT(S)                    GRADE LEVEL                            LENGTH OF SERVICE



Previous Teaching Position:

___________________            _________________              ________________________             ____________________
School Assignment              SUBJECT(S)                    GRADE LEVEL                           LENGTH OF SERVICE



OTHER SCHOOL DIVISIONS:
_____________________________________________       ___________________________            _________________________________
 PRESENT SCHOOL             SUBJECT(S)                    GRADE LEVEL                           LENGTH OF SERVICE




Have you previously been employed as a summer school teacher with Suffolk
Public Schools?
_______YES     _________ NO     If yes, ________elementary     _________middle    __________high




    * Please attach the following: (1) a summary (100 words or less) describing how
    you would motivate reluctant learners and differentiate instruction utilizing
    research based strategies; and (2) a Reading Lesson Plan (120 minutes) to
    include the components of a Balanced Literacy Lesson.
Have you ever been convicted of any offense involving the sexual molestation, physical, or sexual
abuse or rape of a child?          □yes       □ no
I hereby certify that the facts set forth in the above employment application are true and complete to
the best of my knowledge. I understand that if employed, falsified statements on this application shall
be considered sufficient cause for dismissal. You are hereby authorized to make any investigation of
my personal or professional history.

__________________________________________                                 _________________________________________
Applicant’s Signature                                                      Date

Applications from present employees are to be submitted through the principal. Applications from persons not currently employed by our
school division must be submitted to: Human Resources Dept. P.O. Box 1549         Suffolk, VA 23439-1549


APPLICATIONS MUST BE COMPLETED AND RETURNED TO Keesha Hicks BY APRIL6,                                          2012.




FROM PRINCIPAL: (This section ONLY for employees currently under contract to Suffolk Public Schools)

RECOMMENDATION
□   I Do Recommend                    □   I Do Not Recommend

Specific Comments:______________________________________________________________
___________________________________________________________________________________

___________________________                                              ____________________________
Principal’s Signature                                                     Date




Suffolk City Public Schools does not discriminate on the basis of race, color, national origin, sex,
disability, or age in its programs and activities. The following person has been designated to handle
inquiries regarding the non-discrimination policies.
        Kevin L. Alston, Assistant Superintendent of Administrative Services
        100 N. Main Street
        P.O. Box 1549
        Suffolk, VA 23439-1549
        Phone: (757) 925-6750
        Fax: (757) 925-6751
        Email: kevinalston@spsk12.net

								
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