MITCHELL COMMUNITY SCHOOLS

An Equal Opportunity Employer

441 North 8th Street

Mitchell, IN 47446

Telephone: 812-849-4481 Fax: 812-849-2133

Please mail the completed application to the address above or email to:

APPLICATION FOR SUBSTITUTE TEACHERS

Date of Application:
Name:
Home Address:
Telephone: / Home: / Cell: / Work:
Email address:
Social Security Number:

EDUCATION

(High School and College)

Name and Location of School / Date of Degree/Diploma / Diploma Type

Have you ever worked as a substitute teacher? ___ Yes___ No

Please list the school corporations in which you have worked as a substitute teacher:

EMPLOYMENT HISTORY

Dates of Employment / Job Title/Responsibilities / Name/Address/Phone
of Employer / Supervisor’s name / Reason for Leaving

Do we have your permission to contact your previous employers and references? ___Yes ___ No

REFERENCES

Name/Phone Number / Address / Occupation

In what grades and or subjects are you willing to substitute teach?

LICENSE INFORMATION

Indiana Teaching or Substitute Teaching License Number:

Expiration Date:

TEACHER RETIREMENT INFORMATION

If you have previously taught, was retirement held from your pay or paid by the corporation prior to July 1, 1995? __ Yes __ No

Do you hold a teacher retirement number? __ Yes __ No

Teacher Retirement Number: ______

Date retirement number was issued: ______

Are you a retired teacher drawing from teacher retirement? ____ Yes____No

MITCHELL COMMUNITY SCHOOLS

INSERT TO EMPLOYMENT APPLICATION

Request for Background Information

Dear Applicant:

Employment with Mitchell Community Schools of Mitchell, Indiana involves contact with our student population. We ask that you complete the questions below to help us evaluate your suitability to work with these students. All applicants for employment are expected to provide us with this information; you are not being singled out for closer inspection. This insert is part of the application itself and any misrepresentation or omission of fact may be grounds for disqualification from further consideration or for termination from employment regardless of when the misrepresentation or omission is discovered.

The conviction of a crime or any affirmative answer provided by you on this insert is not an automatic bar to employment. Mitchell Community Schools will consider the nature of any conviction or alleged conduct underlying the affirmative response, the date of the alleged conduct in question, your interviewing conduct and the relationship between the offense or alleged conduct underlying the affirmative response and the position for which you are applying.

* * * *

  1. If you are now working, has your conduct as an employee or the quality of your work ever been the focus of any investigation by your current employer? ___Yes ___No

* If yes, explain the circumstances on a separate sheet and attach it to this application.

  1. Have you ever resigned from a job after being disciplined by your employer or after being offeredthe opportunity to resign rather than be terminated? ___Yes ___No

* If, yes explain the circumstances on a separate sheet and attach it to this application.

  1. Have you ever resigned from a prior position (with or without being asked) under circumstances involving your alleged sexual contact with another person, mishandling of funds, or criminal conduct? ___Yes ___No

* If yes, explain the circumstances on a separate sheet and attach it to this application.

  1. Have you ever been investigated for, charged with or plead guilty or “no contest” to, or been convicted of any crime involving the sexual misconduct of any person, indecency with a minor, or any other crime of moral turpitude?

___Yes ___ No

* If yes, explain the circumstances on a separate sheet and attach it to this application. (Moral turpitude is an act of baseness, vileness or depravity in the private and social duties which a person owes another member of society or society in general and which is contrary to the accepted rule of right and duty between persons, including, but not limited to theft, attempted theft, murder, rape, swindling and indecency with a minor.)

  1. Have you ever been charged with a crime, other than a minor traffic offense, where the court has deferred further proceedings without entering a finding of guilt and placed you on probation or in a public service or education program?

___Yes___No

  1. Have you ever been convicted of a crime? ___Yes ___No

* If yes, provide a record of such conviction.

  1. If you have been charged with a crime, please indicate the date of the charge, the court action, the offense in question, and the address of the court involved: (attach additional pages if necessary)

Authorization and Release

I authorize Mitchell Community Schools to check my employment history, including without limitation, reference checks, and to seek the release of investigatory information, including a “limited criminal history,” possessed by any private or public employer or any local, state or federal agency. I authorize these private or public employees or local, state or federal agencies to provide Mitchell Community Schools any information they may release concerning the matters described herein, and I will cooperate to the extent necessary to obtain the release of this information.

I EXPRESSLY WAIVE IN CONNECTION WITH ANY REQUEST FOR, OR PROVISION OF SUCH INFORMATION, ANY CLAIMS OR CAUSES OF ACTION, INCLUDING WITHOUT LIMITATION, DEFAMATION, INFLICTION OF EMOTIONAL DISTRESS, INVASION OF PRIVACY, OR INTERFERENCE WITH CONTRACTUAL RELATIONS THAT I MIGHT OTHERWISE HAVE AGAINST MITCHELL COMMUNITY SCHOOLS, IT’S OFFICIALS, EMPLOYEES, TRUSTEES OR AGENTS, OR AGAINST ANY PROVIDER OF SUCH INFORMATION.

The employer is an equal opportunity employer. The employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excluding any applicant’s consideration for employment on a basis prohibited by local, state, or federal law. This application is current for one year. At the conclusion of this time, if I have not heard from the employer and will still wish to be considered for employment, it will be necessary for me to fill out a new application.

I HAVE READ THIS AUTHORIZATION AND RELEASE OF ALL CLAIMS, AND I EXPRESSLY AGREE TO THE TERMS SET OUT HEREIN.

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