Stepping Stone Preschool and Day Care Center

*We consider applicants for all positions without regard to race, color, religion, sex, national
origin, age, martial or veterans’ status, the presence or no-job related medical condition or
handicap, or any other legally protected status.

Position Applied For: ________________________________

Name: ______________________________________________________

Street Address: __________________________________________

Town, State, Zip: ________________________________________

Phone Number (s): _____________________ or _______________

Email: __________________________________

Are you at least 18 years of age? Yes No

Are you employed now? Yes No May we contact current employer? Yes No
Are you prevented from being legally employed in this country because of Visa or Immigration
status? Yes No

What date are you available for work? ______Full time ______ Part time
Please list past work history:

Name of employer: ______________________________________

Type of work: ______________________ Salary: ___________

Dates employed: ________________________________________

Reason for leaving: ______________________________________

_______________________________________________________

Name of employer: ______________________________________

Type of work: ______________________ Salary: ___________

Dates employed: ________________________________________

Reason for leaving: ______________________________________

_______________________________________________________

Name of employer: ______________________________________

Type of work: ______________________ Salary: ___________

Dates employed: ________________________________________

Reason for leaving: ______________________________________

_______________________________________________________
Applicants Statement

I certify that the answers given herein are true and complete and to the best of my knowledge. I
authorize the investigation of all statements contained in this application for employment as is
necessary in arriving at an employment decision. The applicant understands that neither this
document nor any offer of employment from an employer constitutes and employment contract
unless a specific document in that effect is executed by the employer and employee in writing.
In the event of my employment I understand that false or misleading information given in my
application or interview(s) may result in discharge. I understand that I am required to abide by
all the rules and regulations of the employer. I understand that a physical examination and a
NYS clearance both with results satisfactory to the standards of the Office of Children and
Family Services must be completed before being permanently employed by Stepping Stones.

___________________________________ ____________
applicants signature date

CLEARANCE PROCEDURES
I understand that as required by the licensing agency of the Office of children and Family
Services that I need to be cleared via the SCR (child abuse hotline records) and that I must be
fingerprinted to be cleared via the criminal data base. These are standard for all NYS day care
and family centers. New York State now charges (as of 4/8/11) a fee of $25.00 for this
clearance. This $25.00 will be paid by the center IF you work for at least three months at the
day care center. If you leave before the 3 months, the $25.00 will be deducted from your last
check and listed as a payroll advance.

________________________________ ____________
Signature of applicant acknowledging procedure date

MEDICAL EXAM & TB TEST

I understand as per the regulations of Social Services I must have a medical exam that
includes a TB test within one year of being hired. I must have this form and proof of the TB test
prior to starting to work.

________________________________ ____________
Signature of applicant acknowledging procedure date

CREDENTIALS
I understand as per the regulations of Social Services I must have a high school
diplomas or equivalent. I must be able to bring a copy for us to copy and store in your
personnel file.

________________________________ ____________
Signature of applicant acknowledging procedure date