NAME: LAST NAME FIRST NAME MIDDLE INITIAL

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1 JOHNSTON PUBLIC SCHOOLS 10 Memorial Avenue Johnston, Rhode Island Phone: / Fax: COACH ASSISTANT COACH VOLUNTEER COACH APPLICAT ION FO R EM PLOYM ENT C OA CH / ASSISTANT COACH / V OL U N TEER COACH DATE OF APPLICATION: POSITION APPLYING FOR: Fall Spring High School Middle School NAME: LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NUMBER(S) ADDRESS: EMERGENCY CONTACT: RELATIONSHIP: EMERGENCY CONTACT PHONE NUMBER(S): Dear Applicant: Thank you for your interest in working for the Johnston Public Schools. Your application packet will be considered complete when we have received ALL of the following documents: For Office Use Only Completed Application... Résumé... Three (3) Current Letters of Reference... Copy of Valid Standard First Aid/CPR Certification Card... Copy of Valid RI Concussion & Sudden Cardiac Arrest Certificates... Copy of NFHS Fundamentals of Coaching & RI State Component Certificates... Equal Employment Opportunity (EEO) Form... TB Test Results (No older than 6 months)... National Criminal Background Check (BCI) (No older than 1 year)... W-4 Form... Direct Deposit Form... I-9 Form... 2 Forms of Identification or Passport (see last page)... Page 1 of 15

2 Applications will be kept on file for one school year. 1. PERSO NAL I NFORM AT ION (Please type or print plainly) Have you ever been employed by the Town of Johnston? Yes No If Yes, in what capacity and time frame? 1. Are you a US Citizen or legal resident of the United States? Yes No 2. Have you ever been dismissed from or asked to leave a position of employment? Yes No If you answered Yes to question 2, please explain: 2. EDUCATIO N High School Name & Address of School Course of Study Years Completed Diploma/Degree Earned Undergraduate Graduate/Professional Other (specify) 3. REF ERENCES Please give as references persons other than relatives qualified to answer questions concerning your fitness for the position you seek. Include supervisors or managers for whom you have directly worked. Name / Title Address Telephone Number 4. COACHI NG PREFERENCES Please check ( ) sport(s) you wish to coach: Basketball, Boys Outdoor Track, Boys Hockey Basketball, Girls Outdoor Track, Girls Volleyball Baseball Soccer, Boys Tennis Softball, Girls Soccer, Girls Golf Cross Country, Boys Football Intermural Cross Country, Girls Wrestling Cheerleading Please check ( ) day(s) available for coaching: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Page 2 of 15

3 How did you learn about coaching opportunities in the Johnston School District? SchoolSpring Job Posting Job Reference # Employee Referral Employee Name: Other Please describe: Coaching Recertification Requirement Coaches hired after January 1, 2012 must renew certification every 5 years by fulfilling the requirements listed in Article 13, Section 1B of the RIIL Rules and Regulations, online at (under RESOURCES RULES & REGULATIONS). AFFIRMATION I certify that the information provided in this job application is true and complete to the best of my knowledge and there are no willful misrepresentations or falsifications of any statements. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I agree to execute such form(s) as the Johnston Public Schools may require enabling the Johnston Public Schools to investigate my performance in my current and previous job. I understand and agree nothing contained in this application shall be deemed an employment contract between the Johnston Public Schools and myself for either employment or providing any benefit. I further understand and agree that the granting of an interview shall likewise not create such a contract. No promises regarding employment or inducements to take employment have been made or offered to me and I understand and agree that no such promises are binding upon the Johnston Public Schools unless made in writing. I understand that should an investigation disclose such misrepresentations and falsifications, my application may be rejected. In the event of my employment, I understand that any false or misleading information given in this application or which I have provided by way of a résumé or during interview(s) may result in discharge. I understand, also, that the collective bargaining agreement(s) governing bargaining units may apply to me. CONDITION OF EMPLOYMENT As a condition of my employment, I also agree to abide by any/all Rules, Regulations and/or Policies set forth by the Johnston Public Schools. Policies include but are not limited to the Code of Ethics, Code of Conduct, Sexual Harassment, No Smoking Policy, and others as they may now be in effect or any future Rules, Regulations and/or Policies and/or additions to existing Rules, Regulations and/or Policies as the Johnston Public Schools deems necessary. Applicant Name PRINTED: Applicant Signature: Date: The Johnston Public Schools welcomes diversity in its employment opportunities, programs, and activities. It is the policy of the Johnston Public Schools not to discriminate on the basis of age, sex, marital status, race, religion, national origin, color, political affiliation, or handicap in its employment practices. Inquiries regarding compliance with Equal Opportunity/Affirmative Action may be directed to: Johnston Public Schools Administration Office, 10 Memorial Avenue, Johnston Rhode Island 02919, ATTN: Equal Opportunity/Affirmative Action Officer The Johnston Public Schools is subject to the provisions of the Workers Compensation Act. Page 3 of 15

4 EEO: EEO-1 Voluntary Self Identification Form The Equal Employment Opportunity Commission (EEOC) requires organizations with 100 or more employees to complete an EEO-1 report each year. Completion of this data is voluntary and will not affect your opportunity for employment or terms or conditions of employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by the Human Resources Department. NAME: JOB TITLE: GENDER: (Please check ) Male Female RACE/ETHNICITY: (Please check one of the descriptions below corresponding to the ethnic group with which you identify.) Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (Not Hispanic or Latino) A person having origins in any of the original peoples of Europe, the Middle East or North Africa. Black or African American (Not Hispanic or Latino) A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands. Asian (Not Hispanic or Latino) A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. American Indian or Alaska Native (Not Hispanic or Latino) A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. Two or More Races (Not Hispanic or Latino) All persons who identify with more than one of the above five races. DATE COMPLETED: Thank you for your participation. Page 4 of 15

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7 JOHNSTON PUBLIC SCHOOLS 10 Memorial Avenue Johnston, Rhode Island Phone: / Fax: Johnston Police Department 1651 Atwood Avenue Johnston, RI ATTN: BCI Department OR OR Attorney General s Office Local Police Department CONDITIONAL LETTER OF INTENT TO HIRE As part of our employment application requirement, the holder of this letter is seeking employment with the Johnston Public Schools and is in need of a National and State Criminal Background Check in accordance with the Rhode Island General Laws 1. 1 National and State Criminal Background Check Rhode Island General Laws Criminal records review., Prior criminal records checks. (a) Any person seeking employment with a private school or public school department who has not previously been employed by a private school or public school department in Rhode Island during the past twelve (12) months shall undergo a national and state criminal background check. Page 7 of 15

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12 Johnston Public Schools Payroll Direct Deposit Authorization EMPLOYEE NAME (PLEASE PRINT): DATE OF BIRTH: Direct Deposit Request & Authorization From my net pay each pay period, I hereby authorize and request you to: Bank Name Router # Acct. # Chk. Sav. Bi-weekly Amount $ $ $ If you would like the entire balance of your net pay to be deposited, please indicate BALANCE in the Amount column. NOTE: This form will replace any previously submitted Direct Deposit authorization forms; therefore, must be completed in its entirety including ALL (present and additional) bank names, router numbers, account numbers and amounts. If possible, PLEASE ATTACH A VOIDED CHECK for each account listed to this request. This authorization may be cancelled at any time by written notification to the company. Any such notification shall be effective only after the company has had reasonable time to act upon it. EMPLOYEE SIGNATURE: DATE: FOR OFFICE USE: PAYROLL SIGNATURE: DATE ENTERED: Page 12 of 15

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