Employment Application

Pre-Employment Application

PERSONAL INFORMATION - Step 1 of 3

Date of Application:

Applicant Name:

First

Middle

Last

If your records are listed under another name, please list that name here:

ADDRESS:

Address Line 1

City

State

Zip Code

SEX:

Male
Female

Primary Phone:

Email:

Are you legally eligible for employment in the U.S. ?

Have you been convicted of child abuse or neglect ?

Have you applied here or worked here before:

If yes, date and Job title:

Have you previously worked for MDCPS?

If yes, Employee:

Are working now?

Date You are available to begin work:

How did you hear about this position?

What position are you applying for?

DIRECT CARE STAFF
SUMMER CAMP
BEFORE CARE
AFTER CARE
OFFICE/ ADMINISTRATIVE STAFF
JANITORIAL/ SECURITY PERSONNEL

Name of Employer:

Supervisor Name/Title:

Full Address/Phone number of Employer:

Position(s) Held:

Reason for leaving:

Describe the work performed:

May we contact them for a reference?

If no, why not?

Name of Employer:

Supervisor Name/Title:

Full Address/Phone number of Employer:

Position(s) Held:

Reason for leaving:

Describe the work performed:

May we contact them for a reference?

If no, why not?

REFERENCES

Name:

Occupation:

Relationship to You:

How Long have you Known this person?

Email Address:

Phone Number(s):

Name:

Occupation:

Relationship to You:

How Long have you Known this person?

Email Address:

Phone Number(s):

Name:

Occupation:

Relationship to You:

How Long have you Known this person?

Email Address:

Phone Number(s)

Please identify the education or training which you believe qualifies you for the position you seek. Formal Education (check all that apply):

GED/High School Diploma
Associate Degree Major
Bachelor’s Degree Major
Master’s Degree Major

Have you completed any trainings or certification courses related to caregiving or home health aide?

Please list any courses or certifications below:

Are you CPR Trained ?

Are you willing to submit to a drug test? (if offered a position)

Are you willing to complete a Level II Background Screening? (if offered a position)

ADDITIONAL TRAINING / KNOWLEDGE

Please list any additional training you have received related to the position you are applying for, especially any trainings related to Applied Behavioral Analysis (ABA), Registered Behavior Technician (RBT), Behavioral Management and/or Autism Spectrum Disorders (ASD). Did you receive a certification?

Please list any other knowledge, skills, or traits not previously mentioned that would help you perform the essential functions of this position.

PERSONAL STATEMENT

Please list three values that are important to you and give reasons why. Limit the response to the area provided.

OVERALL JOB DESCRIPTION

The activities described below are expected and required of all staff. Upon offer of employment, a more detailed job specific list of duties will be provided.

SFA-Center employees are assigned to specific exceptional students/program participants to enable them to access programs by using appropriate behavior management techniques and professional methods and practices associated with the needs of the students. Work is performed under close supervision of a certified teacher or professional support staff and is subject to specific, detailed instruction.

1. Physically aids the assigned exceptional student/participant classified as ESE-ASD, in the area of assignments and the utilization of specific teaching or professional practices associated with the student’s needs.
2. Aids the assigned exceptional students/ using behavioral management/modification programs.
3. Works with the assigned exceptional student/participant to achieve planned goals, utilizing special techniques.
4. Supports the implementation of the individualized educational plan (IEP) for the assigned exceptional student regarding goals and benchmarks, as directed, may perform routine clerical tasks specifically related to the assigned exceptional student to produce instructional and behavioral materials.
5. Maintains and monitors the schedule of prescribed medications if needed for the assigned exceptional student/participant.
6. May be required to carry out School Board approved physical restraint procedures with the assigned exceptional student/participant if they present a danger to self and/or others (training will be provided).
7. May assist in toileting, feeding and dressing.
8. Performs related duties of instructional or clerical nature as required.
9. Participates in required professional development, as directed.
10. Participates in required special events, as directed.

This work requires the following physical activities: climbing, bending, reaching, sitting, standing, walking, pushing, pulling, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The worker is exposed to cold, heat, noise, perilous behavioral incidents and atmospheric conditions. The work is performed indoors and outdoors

Please sign that you have read and understand the above job description. By signing below, you agree to perform various tasks listed above as part of your daily work-related duties.

Name (Printed) :

Signature :

Date :

South Florida Autism Center considers applicants for all positions on the basis of their qualifications and without regard to race, color, national origin, citizenship, religion, sex, pregnancy, age, disability, genetic information/history, military status, use of lawful products during non-work hours, sexual orientation, gender identity and expression and/or any other legally protected characteristic or condition.

Name