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Activity Leader Application
Personal Information:
Name:
First Last Middle
Address:
City: State: Zip Code:
Day Phone: Evening Phone:
Cell/Pager: E-Mail:
Date of Birth: Social Security #:
Gender: Ethnicity (for criminal history check):
Driver’s License #: State in which issued:
List all stated that you have resided in during the past five years:
Have you ever worked or attended school under any other name? Yes No
If yes, what name/s?
Have you ever been convicted of a crime? Yes No
If yes, please attach a statement giving a full explanation. (Exclude those cases contained within an expunged juvenile record and minor traffic violations.)
SOAR classes you are interested in coordinating and teaching:
Please check all that apply:
I would like to teach a: K/1 class 2/3 class 4/5 class
Tutoring Family Education class
I would like to teach on: ___Mondays ___Tuesdays ___Wednesdays ___Thursdays ___Fridays
I would like to teach: ___Block 1 (3:30-4:25pm) ___Block 2 (4:30-5:25pm) ___Both Blocks
I would like to teach: ___Fall 2006 ___Winter 2007 ___Spring 2007 ___Summer 2007
Special Training or Skills: (List any special training, licenses, certificates, computer skills, or other special skills/interests you may have that are pertinent to the position for which you are applying.)
Membership in Professional/Civic Organizations or Volunteer Activities:
Education Completed (Include High School/GED Program)
Name of School: |
Location: |
Major or Studies: |
Degree/Certificate Completed or Hours Completed/Years Attended |
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Employment History:
1) Last or Present Employer: Job Title:
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Reason for Leaving: |
Hrs/Wk |
Full Time
Part Time |
Supervisor: Phone Number: |
Date Started |
Date Ended |
Salary/Rate of Pay:
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Address: City: State: Zip Code: |
Describe Specific Duties: |
2) Previous Employer: Job Title:
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Reason for Leaving: |
Hrs/Wk |
Full Time
Part Time |
Supervisor: Phone Number: |
Date Started |
Date Ended |
Salary/Rate of Pay:
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Address: City: State: Zip Code: |
Describe Specific Duties: |
References: List four people who are: 1) not related to you, 2) are over 18 years old. Two must be professional and two personal references who have known you for more than three years.
Full Name: Telephone: Professional/Personal: Years Known:
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Read the following carefully before you sign.
- Due to the nature of the work involved with PAL, all prospective employees and volunteers will be subject to a criminal history check. This check is confidential and open to explanations. By signing on the line below, you are both authorizing this background check and confirming that all information listed about is valid and truthful to the best of your knowledge.
- A false statement on any part of your application will be grounds for not selecting you, or for removing you from the PAL/SOAR staff after you have been selected.
- I consent to the release of information about my ability and fitness for service as a PAL/SOAR staff member by my workplace, schools, law enforcement agencies, and other individuals and organizations, to investigators, personnel staffing specialist, and other authorized employees of PAL.
Signature: Date:
Submit completed application to:
SOAR, c/o Molalla PAL, PO Box 726, Molalla, OR 97038, Fax #: 503-829-2614
SOAR is an Equal Opportunity Employer and does not discriminate based on: gender, race, religion, color, culture, national origin, disability, sexual orientation, age, veteran, or marital/parental status. |
