"Certificated of Employment"
St. John-Endicott Cooperative School Districts CERTIFICATED EMPLOYMENT APPLICATION This application form will be used as a working document by the screening committee. Please fill in all blanks (Do NOT state “See attached”, etc. or leave questions unanswered). If there is insufficient space for you to respond to questions, use additional paper and indicate which questions you are continuing to answer. Please TYPE or PRINT in black ink so this can be photocopied. Last Name First Name Middle Name/Initial Present Address City State Zip Telephone Permanent Address City State Zip Telephone EMPLOYMENT HISTORY: Please list all experience in reverse chronological order. Be specific: state level/subjects taught, title, e.g. Position/Title Organization/Location Grade Level Dates EDUCATION: (Undergraduate & Graduate) Institution Dates Attended Major/Minor Degree WASHINGTON STATE TEACHING CERTIFICATE NUMBER: Are you under contract? If so, until when? What is your present position? If you are not selected for this position would you be willing to substitute? St. John-Endicott Cooperative School Districts are Equal Opportunity Employers. PROFESSIONAL INFORMATION SUMMARY: TEACHING LEVEL PREFERENCE: Primary K-3 Intermediate 4-6 Middle School 7-8 Senior High 9-12 SUPPLEMENTAL NON-TEACHING PREPARATION AND COMPETENCY: Counselor Elem Administration Librarian Psychologist Secondary Administration School Nurse Other LIST COACHING EXPERIENCE & INTEREST LIST OTHER AREAS OF LEADERSHIP ENDORSEMENT AND PREPARATION AREAS: (List the areas you are endorsed to teach) PREPARATION AREAS: Major Minor Major Minor Major Minor I have requested my placement file to be forwarded from: Placement Office Address City State Zip St. John-Endicott Cooperative School Districts are Equal Opportunity Employers. REFERENCES: (Please list the names of four persons who know of your current professional work and qualifications) Name Position Address Office Phone Home Phone City State Zip Name Position Address Office Phone Home Phone City State Zip Name Position Address Office Phone Home Phone City State Zip Do you place any restriction on contacting these and other references? Yes No Comments: Within the last seven years have you ever plead guilty, been convicted, fined, imprisoned or placed on probation for violation of any law, police regulation or ordinance (excluding minor traffic violations)? (A conviction record will not necessarily bar you from employment.) Yes No Within the last 20 years have you ever been discharged or forced to resign for misconduct or unsatisfactory service from any position – teaching or other? Yes No If yes, please explain Have you ever had a certificate revoked, suspended or denied, or have you voluntarily relinquished a teaching certificate to avoid revocation procedures? Yes, No If Yes, which State: St. John-Endicott Cooperative School Districts are Equal Opportunity Employers. To assure that you have a completed file in our office, please check the following: 1. Completed application form. 2. Professional Reference Forms have been sent to appropriate people to be forwarded to St. John School District upon completion. (At least two must be returned and one must be from your most recent supervisor. In the case of student teachers, one form should be completed by your supervising teacher.) 3. Copies of all college/university transcripts. 4. College placement file has been forwarded. 5. Copy of your teaching certificate. 6. Current resume. GENERAL INFORMATION: 1. A limited number of finalists for any position will be invited for a personal interview. A personal interview is required before an applicant can be recommended for employment. 2. If elected, the applicant agrees to accept assignments to subjects and activities as made by the superintendent and school board. 3. The School District accepts applications for specific openings only. This application will be kept in our files until October 1, following the date of receipt. 4. University placement credentials, resume, and all application materials should be mailed to: St. John-Endicott Cooperative School Districts, ATTN: Dana Crider, W 301 Nob Hill, St. John, WA 99171. I hereby certify that all the information I have provided is true and correct, I give my permission for St. John- Endicott Cooperative Districts to contact any references or prior employers given in conjunction with this application. I further agree that if I am employed, I will provide verification of my certification, education and experience. I also agree that falsification of any part of this application shall be sufficient cause for dismissal. References and personal information, which become a part of this application will be regarded as confidential and shall not be revealed to me. Signature of Applicant Date St. John-Endicott Cooperative School Districts comply with federal rules and regulations that prohibit discrimination based on race, gender or disabilities in employment or participation in programs or activities. Direct inquiries to: Dana Crider, Business Manager, St. John-Endicott Cooperative Schools, W 301 Nob Hill, St. John, WA 99171 (509) 648-3336). St. John-Endicott Cooperative School Districts are Equal Opportunity Employers. INSTRUCTIONS: Please answer the following questions in your own handwriting. Why are you applying for a position in the St. John-Endicott school districts? What experience or preparation have you had which qualifies you for teaching in a rural school district? Additional information which in your opinion may help further your consideration for a certificated position in the cooperative schools? St. John-Endicott Cooperative School Districts are Equal Opportunity Employers. TO: All Employees FROM: Rick Winters, Superintendent DATE: September 1, 2005 RE: Drug-Free Workplace Act NOTICE TO EMPLOYEES – DRUG AND ALCOHOL POLICY You are hereby notified that it is a violation of the policy of the St. John and Endicott School Districts for any employee to unlawfully manufacture, distribute, dispense, possess, use or be under the influence of any narcotic drug, hallucinogenic drug, amphetamine, barbiturate, marijuana or any other controlled substance as defined in Schedules I through V of Section 202 of the Controlled Substances Act (21 U.S.C. 812) and as further defined by regulation at 21 CVR 1300.11 through 1300.15, before, during or after school hours on school property or in any other School District location as defined below. “School District location” means in any school building and on any school premises; in any school-owned vehicle or in any other school-approved vehicle used to transport students or staff to and from school or school activities; off school property during any school-sponsored or school approved activity, event or function, such as a field trip or athletic event; or, during any period of time such employee is supervising students on behalf of the School District or otherwise engaged in school District business. You are further notified that if you are engaged either directly or indirectly in work on a Federal grant, it is a condition of your continued employment under any such Federal grant that you abide by the terms of the School District’s policy on drugs, and will notify your supervisor, in writing, of your conviction of any criminal drug statute for a violation occurring in any of the places listed above on which work on a School District Federal grant is performed no later than five (5) days after such condition. Any employee who violates the terms of this policy shall be subject to appropriate disciplinary action up to, and including, discharge. The employee may, under appropriate circumstances at the discretion of the District, be required to satisfactorily participate in a drug or alcohol rehabilitation program. St. John –Endicott Cooperative School Districts APPLICANT DISCLOSURE FORM PURSUANT TO CHAPTER 486, LAWS OF 1987 Please Note: A background check with the Washington state Patrol will be conducted on all certificated and all unsupervised classified employees and volunteers, and may be initiated on any other classified employees and volunteers. Answer YES and NO to each listed item. If the answer is YES to any item, explain in the area provided, indicating the charge or finding, the date and the court(s) involved. 1. Have you ever been convicted of any crimes against persons as defined in section 1 of Chapter 486, Laws of 1987, and listed as follows: Aggravated murder, first or second degree murder; first or second degree kidnapping; first, second, or third degree assault; first, second, or third degree rape; first, second, or third degree statutory rape; first or second degree robbery; first degree arson; first degree burglary; first or second degree manslaughter; first or second degree extortion; indecent liberties; incest; vehicular homicide; first degree promoting prostitution; communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of minors; first or second degree criminal mistreatment? No Yes If yes, explain 2. Have you ever been found in any dependency action under RCW 13.34.030(2)(b) to have sexually assaulted or exploited any minor or to have physically abused any minor? No Yes If yes, explain 3. Have you ever been found by the court in a domestic relations proceeding under Title 26 RCW to have sexually abused or exploited any minor or to have physically abused any minor? No Yes If yes, explain 4. Have you ever been found in any disciplinary board final decision to have sexually abused or exploited any minor or to have physically abused any minor? No Yes If yes, explain Pursuant to RCW 9A.72.085 I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Applicant Signature Date Witness (with knowledge of applicant) Witness Address and Phone Number St. John-Endicott Cooperative School Districts are Equal Opportunity Employers. St. John-Endicott Cooperative School Districts Certificated Pre-Employment Information Confidential Failure to provide the information requested below will not jeopardize or adversely affect the consideration you receive for employment. However, your answers will help ensure that our affirmative action program results in fair representation of employment and assist us in meeting requirements for periodic reporting of our work force composition. This form will be separated from your application before any evaluation of candidates is undertaken. Sex: Male Female Date of Birth: Race/Ethnic Origin: American Indian or Alaska Native Hispanic Asian or Pacific Island White Black Other __________ Race/Ethnic Origin Definitions: American Indian or Alaskan Native: A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition. Asian or 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. Black: A person having origins in any of the Black racial groups of Africa. Hispanic: A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race. White/Caucasian: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East. Disabilities: “Disabled individual” means any person who (1) has a physical or mental impairment which substantially limits one or more of such person’s major life activities, (2) has a record of such impairment, (3) is regarded as having such an impairment, or (4) has a known relationship or association with a disabled person. I am disabled as defined: Yes No Recruitment Source: Please indicate the publication or other source where you obtained information regarding this position notice so we can determine the effectiveness of various recruitment efforts: St. John-Endicott Cooperative School Districts are Equal Opportunity Employers. WASHINGTON This Form is Confidential SCHOOL PERSONNEL The applicant noted on this form has given authorization to obtain information from listed references. ASSOCIATION Eastern Washington school districts accepting this form include but are not limited to: Central Valley, Deer Park, Region 1 East Valley, Mead, Riverside, Spokane, West Valley. APPLICANT’S NAME: has applied for a certificated non-administrative position. How long have you known this applicant? What school year(s) did you observe this applicant? Where? and in what capacity did the applicant work with you? What was your title at the time? In what capacity do you evaluate this applicant? As supervisor/evaluator How long? As colleague How long? REFERENCE WRITER PLEASE NOTE: Please rate this applicant on a scale of 1 to 7, with 1 being low and 7 being high, in each of the following factors. Compare this individual to all others you have observed. Check only one box per factor. You may receive a telephone call to confirm/verify your responses. Low High Not FACTORS 1 2 3 4 5 6 7 Observed 1. Classroom Management. Effectively manages large and small groups, and individuals; creates an atmosphere conducive to learning by developing routines and procedures to increase learning. 2. Behavior Management/Discipline. Establishes and uses appropriate behavior management procedures; recognizes conditions which may lead to discipline problems; establishes clear parameters for student behavior; develops strategies to prevent discipline problems; responds appropriately when problems occur; assists students toward self-discipline. 3. Flexibility. Willing to learn new concepts and ways of doing things; cooperates with youth and adults; effectively uses various teaching styles; successfully teaches a variety of assignments; adapts to others in a team, staff, or parent situation. 4. Instructional Skills. Plans, implements, and evaluates instructional activities; has knowledge of, and applies current approaches to teaching new ideas and skills; uses a variety of styles/methods which reflect planning and pacing skills appropriate to students; monitors results and takes appropriate action; assesses students’ needs, prescribes programs, and provides strategies appropriate to age, background and intended learning of students. 5. Commitment to Accomplishment for Self and Others. Establishes high expectations for self and students; exerts effort to attain goals; organizes, predicts, and monitors ideas, time, materials, and space to cause achievement to take place. 6. Relation to Students. Develops favorable relationships with students; exhibits empathy and responds to student needs; listens, has patience, and demonstrates caring; accepts students as they are; is considered open and approachable by students; works collaboratively with students in decision-making. 7. Understands/Appreciates Multicultural and Diverse Populations. Relates positively to youth and adults of varying socioeconomic, cultural, racial/ethnic backgrounds, different learning styles, and various disabilities; adjusts classroom activities to reflect the diversity of students. 8. Scholarship and Conceptual Skills. Demonstrates ability to learn new ideas and skills for substantive and methodological aspects of teaching, for learning initial information necessary to function in the local setting, for applying new concepts during teaching, as the job changes, and in solving problems. 9. Enthusiasm. Exhibits appropriate overall optimism and zeal, using them to motivate student learning. Uses facial expressions, body language, and presentation skills that demonstrate a caring and warmth toward students and an enthusiasm for learning. 10. Professional Orientation/Collaboration. Possesses an awareness of current educational developments and their applications, including learning, child development and approaches to teaching; demonstrates a willingness to work collaboratively at the building and district level, effectively building relationships and responding positively to constructive comments and supervision; holds a strong belief in the importance of education; sincerely interested in the welfare of all students and in solving problems by consensus. 11. Technology Literacy. Makes appropriate use of available technology in relation to planning activities, learning activities, and record keeping; integrates technology into the learning process. Print Name: Signature: Address: Date: Office Phone: Message Phone: Please make any comments you feel would be helpful for us to know on the other side of this page. Writers of References – Please read this before filling out other side. Comments: Your willingness to provide us with your honest opinion of the applicant identified on this form is greatly appreciated. The selection of personnel is a very important task in any organization, and the information provided by people who know applicants is valued highly. Please rate this applicant in each category by comparing the individual with all others you have observed teaching. Be careful not to skew ratings in a positive direction. When this happens, applicants begin to look very similar and the reference material is not as beneficial in helping us discern which applicants are stronger. We encourage you to be as honest as possible. Your assistance toward our making good decisions concerning a fit between an individual and a position in the district is greatly appreciated. Again, we want to thank you for the courtesy of providing us with your opinions. If you have any questions concerning any aspect of the form or how it will be used in the selection process, please call the Human Resources office. After completing this form, please fold this side out, insert in an envelope, sign across the flap, and return it to the applicant (or mail it directly to the district). Thank you.