Saint Louis Crisis Nursery
Regional Administrative Offices
11710 Administration Drive, Suite 18
St. Louis, MO 63146
Phone: 314-292-5770
Fax: 314-292-5776
Last Name: First Name:
Middle Initial: Maiden Name:
Address:
City: State: Zip Code:
Phone (With Area Code): Cell Other
Email address:
Name of College or University:
Degree in process: Associates Bachelor’s Master’s
Field of Study: Total hours needed:
Desired start month/ year: Anticipated completion date:
List Days and times available to complete hours:
Desired location(s): StL City StL South County StL North County St. Charles City Wentzville
How did you hear about the Crisis Nursery opportunity?
Please list all states you have worked in, lived in, or attended school in, within the last 5 years:
Do you have a Social Security Card? Yes No
If no, do you have the means to obtain one? (licensing requirements) please explain:
Have you ever been convicted of a crime other than a minor traffic violation? Yes No
If yes, please explain (a conviction will not necessarily disqualify an applicant):
Please review and initial indicating your understanding and agreement:
The Saint Louis Crisis Nursery is a smoke and tobacco free environment
All students are expected to remove piercings (except in ear lobes) and cover body art while at the Nursery or representing the Nursery.
All practicum placements are conditional on the acceptable results of background screenings which include the Family Care Safety Registry and fingerprinting that is run nationwide through the FBI. Please consider whether it is in your best interest to pursue a practicum with the Nursery, as fingerprinting is at the cost of the student and the Crisis Nursery is unable to refund fees if placement is not approved.
PLEASE READ THIS STATEMENT CAREFULLY, SIGN AND DATE BELOW.
This document serves solely as a clear and conspicuous written disclosure as required by the Federal Fair Credit Reporting Act set forth in Section 604(b) to the Applicant that previous employment, education, social security, credit, motor vehicle report, and a criminal background check may be obtained for the purpose of this application only. Your signature below acknowledges that the Saint Louis Crisis Nursery has made this disclosure.
I certify that answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application as may be necessary in arriving at a placement decision.
I authorize the Crisis Nursery to investigate, obtain, compile, examine, copy, or receive any records pertaining to this application, and without reservation allow The Crisis Nursery to release and/or discuss any information about my history with authorized personnel of the Department of Social Services. I further authorize the Department of Social Services to share any personnel information that the Department of Social Services may have about me with my employer or prospective employers as the Department determines necessary to make personnel decisions regarding my suitability to provide services with my employer. By authorization of the above, I agree to hold harmless any individual, partnership, corporation, educational institution, or agency, The Department of Social Services, the Missouri Children’s Division, it’s officers, agents and employees, as well as the State of Missouri, from any liability for any damage whatsoever for issuing such information.
This application contains no misrepresentation or falsifications and the information given is true and complete to the best of my knowledge and belief. I am aware that, should an investigation at any time disclose any such misrepresentation or falsification as to a material fact, the application will be rejected or, if selected, I may be dismissed by the employer/contractor.
Print Name: Date:
Signature of Applicant:
by checking this box I certify that I have signed this application
12/20/2017