SOUTH WHIDBEY SCHOOL DISTRICT No. 206 5520 Maxwelton Road Langley, WA 98260 answer all questions (360) 221-6100 FAX (360) 221-3835 print in ink or type www.sw.wednet.edu attach additional sheet(s) if necessary APPLICATION FOR COACHING EMPLOYMENT APPLICATION FOR: (Position Desired) NAME OF APPLICANT: PRESENT MAILING ADDRESS: Last First Middle Number/street City/State Zip Email address Telephone Number Cell Phone Number Do you have current First Aid/CPR training? Yes: No: If yes, please attached copy of documentation. COLLEGE AND UNIVERSITY TRAINING College or University City & State Dates Major Minor Degree CERTI FI CATED EXPERI EN CE List your latest experience first: Part-time or Number of Dates: School & Location Grades and Subjects Taught Full-time Months From To Will sponsor or coach the following activities or athletics: The South Whidbey School District #206, an Equal Opportunity Employer, does not discriminate on the basis of sex, race, creed, religion, color, national origin, age, marital status, honorably discharged veteran or military status, sexual orientation including gender expression or identity, the presence of any sensory, mental, or physical disability, or the use of a trained dog guide or service animal by a person with a disability in its programs and activities and provides equal access to the Boy Scouts and other designated youth groups. Protected groups are invited to apply. The following employees have been designated to handle questions and complaints of alleged discrimination: Affirmative Action/Title IX/ RCW 28A.640 /RCW 28A.642 compliance officer, Dan Poolman, dpoolman@sw.wednet.edu, or Section 504/ADA coordinator, Dr. Jeff Fankhauser, jfankhauser@sw.wednet.edu, 5520 Maxwelton Road, Langley, WA 98260, 360-221-6100 As a condition of employment, newly hired employees are required to be fingerprinted and provide information for a Washington State Patrol and FBI History background inquiry at a personal cost of approximately $53.00. Any offer of employment will be conditioned on satisfactory results of the background check for criminal history or other disqualifying information.
CO ACHI N G EXPERI EN CE List your latest experience first: Agency / Location Job From To GEN ERAL Are you able to perform the essential functions of the job (refer to the attached job description) with or without reasonable accommodation? Please specify any work with children or youth: Other skills, interests, hobbies or abilities Have you been convicted of a felony within the last 7 years? Yes No [Conviction will not necessarily disqualify applicant from employment] If Yes, please explain REFEREN CES M ust be per sons other than your Let t ers of Recommendat ions. Name Phone & Email Contact Information Position I hereby certify that the information herein is a true and complete statement of my personal and professional record to date, and understand that willful falsification of information on this form shall be grounds for immediate dismissal or withdrawal of my application. I hereby authorize any former employer, person, firm, corporation, educational or vocational institution or government agency to provide South Whidbey School District with information they have regarding me, and I agree that the references and personal information which become part of this application will be regarded as confidential and shall not be revealed to me. I hereby release and discharge South Whidbey School District and those who provide South Whidbey School District with information from any and all liability as a result of furnishing and receiving this information. Signature of Applicant Date
Name: Date: EMPLOYMENT HISTORY DISCLOSURE 1. Are you presently under contract/employed? - If yes, with whom? What is your present position (Title)? 2. Are you a former employee of our District? - If yes, dates and position 3. Have you ever been placed on a performance improvement plan or placed on probation? 4. Have you ever been placed on administrative leave and/or suspended pending investigation of allegations of misconduct? 5. Have you ever had any license or certificate of any kind (teaching certificate or other professional certificate or license) revoked, suspended or reprimanded, or have you in any way been sanctioned by, or is any charge or complaint now pending against you, before any licensing, certification or other regulatory agency, or body, public or private? 6. Have you ever resigned or otherwise separated from any employment (including regular or extracurricular positions) in order to avoid discharge or non-renewal? 7. Have you ever been discharged or non-renewed from any employment (including regular or extracurricular positions)? 8. Have you ever been disciplined for misconduct by a past or present employer? 9. If you answered YES to questions 3, 4, 5, 6, 7, or 8, provide an explanation of the circumstances below, including the underlying facts, place, date, and outcome. CRIMINAL HISTORY DISCLOSURE 1. Are you presently charged with, but not convicted of, a crime? (Exclude civil infractions, such as minor traffic citations.) If yes, include an explanation of the nature of the charge, place, date, and court. A pending criminal charge will not necessarily bar you from District employment.
2. In the last ten (10) years have you been convicted of a crime? (The term convicted means all adverse dispositions, including a finding of guilty, a plea of guilty or nolo contendere, an Alford plea, a stipulation to the facts, a deferred or suspended sentence, or a deferred prosecution. Exclude civil infractions, such as minor traffic citations.) If yes, include an explanation of the nature of the crime, place, date, and court. A conviction record will not necessarily bar you from District employment. 3. Have you ever been (a) found by a court in a protection proceeding under Chapter 74.34 to have abandoned, abused, neglected or financially exploited a vulnerable adult or (b) convicted of any of the following crimes where the victim was a vulnerable adult: (Vulnerable adult means adult as defined by Chapter 74.34 and adults of any age who lack the functional, mental, or physical ability to care for themselves.) First, second, or third degree extortion Forgery First or second degree robbery First second or third degree theft Any of the foregoing crimes as they may have been renamed 4. In the last ten (10) years have you been convicted of any crime involving the manufacture, delivery, or possession with intent to manufacture or deliver a controlled substance? 5. Have you ever been found in any dependency action under RCW 13.34.040 to have sexually assaulted or exploited any minor or to have physically abused any minor? 6. Have you ever been found by a court in a domestic relations proceeding under Title 26 RCW or in a criminal proceeding under Chapter 9A.44 RCW to have sexually abused or exploited any minor, or to have physically abused any minor?
7. Have you ever been found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person, or to have abused or financially exploited any vulnerable adult? Disciplinary board final decision means (a) any final decision issued by the director of the Department of Licensing for real estate brokers and salespersons and (b) any final decision issued by a disciplinary authority under Chapter 18.130 RCW or the secretary of the Department of Health for the following businesses or professions: chiropractic, dentistry, dental hygiene, naturopathy, massage, midwifery, osteopathic medicine and surgery, physical therapy, physicians, practical nursing, registered nursing, and psychology. 8. Are you now being investigated for any alleged misconduct or other alleged grounds for discipline by any licensing, certification, or other regulatory body (teacher certification or otherwise) or by your current or any previous employer? If you answer Yes, you must provide the name, address and telephone number of the employer or licensing body and statement of the accusation against you. 9. Have you ever been a party to, or are you currently a party in, or do you anticipate becoming a party in, litigation involving South Whidbey School District? Applicant Signature: An inquiry may be made to the Washington State Patrol, a Federal, or other Law enforcement agency to verify your responses to the above inquiries. A copy of any response received pursuant to such inquiry will be made available to you upon request. I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Applicant, Printed Name: Applicant Signature: Date and Place: TO BE COMPLETED ONLY AFTER CONDITIONAL EMPLOYMENT IS OFFERED BY THE DISTRICT AND AS INSTRUCTED BY DISTRICT STAFF I certify under penalty of perjury that as of this date / /, a date on or after which I have been offered conditional employment with South Whidbey School District, the foregoing remains true and correct. Your signature must be witnessed Print Name: Sign Name: Witness, Print Name/Title: Date and Place:
South Whidbey School District is an Equal Opportunity Employer We are committed to an affirmative action program that provides for the recruitment of women, people of color, people with disabilities, people over 40 and veterans. If you have decided to apply for this position, we would appreciate your voluntary cooperation in responding to the questions This information will assist in ensuring equal employment opportunity and is strictly confidential, available only to authorized staff and is not shared with the hiring decision-makers. Name Date 1. ETHNIC GROUP: Check either Yes or No Hispanic/Latino YES No 2. RACE CATEGORIES: Check all that apply: AMERICAN INDIAN/ALASKA NATIVE (I): A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. ASIAN (A): A person having origin 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. BLACK (B): A person having origins in any of the Black racial groups of Africa. NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER (P): A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. WHITE (W): A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. 3. Are you: Male Female 4. Have you ever been on active duty in the U.S. Armed Services? Yes If yes, dates you served: No From to Disabled veteran? Yes No Percentage of disability % 5. Do you have any physical, sensory, or mental condition that limits any of your major life functions? Yes No 6. Are you in the protected age group (age 40 or over)? Yes No Thank you.