GENDER
/ /FULL NAME
MALE / LAST NAME / FIRST NAME / INITIALFEMALE / /
HOME ADDRESS
NUMBER / STREET / APT. NO.CITIZENSHIP
U.S. CITIZEN / CITY / STATE / ZIP
NOT U.S. CITIZEN / HOME PHONE # / ()
EMPLOYEE ID # / DATE OF BIRTH
MARITAL STATUS / PREVIOUSLY EMPLOYED BY THE CITY SCHOOL DISTRICT? / YES / NO
MARRIED / EMPLOYEE’S MAIDEN NAME
SINGLE / EMAIL ADDRESS
ETHNIC BACKGROUND
This data is requested in order that we may comply with various Federal and State regulations requiring ethnic distribution information. Data is confidential. It will be available only in summary form for research and statistical purposes, and only upon specific authorization and for non-discriminatory use. Please check the box that applies to you based upon your predominant ethnic background.
£
£
£ / Black/African American: A person having origins in any of the black racial groups of Africa.
White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Hispanic/Latino: A person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. / £ / Asian: A person having origins 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.
£ / American Indian/Alaska Native: 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.
EMERGENCY NOTIFICATION / I am interested in working as a Per Diem with the Rochester City School District for the 2012-2013 school year.
NAME
ADDRESS / Please select one (1) area below:
£ / per diem Teacher - Certified
PHONE # / () / £ / per diem Teacher - Uncertified
RELATIONSHIP Spouse Parent Child Other / £ / COUNSELOR - CERTIFIED
£ / per diem PSYCHOLOGIST
EDUCATIONAL LEVEL / £ / per diem SPEECH - CERTIFIED
£ / NOT HIGH SCHOOL GRADUATE / £ / VOC. EQUIV. TO BACHELOR’S / £ / per diem Administrator
£ / HIGH SCHOOL DIPLOMA / £ / MASTER’S DEGREE / £ / per diem Retiree / Test Corrector
£ / EQUIVALENCY DIPLOMA (GED) / £ / CERT. BEYOND MASTER’S / £ / per diem Sentry
£ / ASSOCIATE’S DEGREE / £ / DOCTORATE
£ / BACHELOR’S DEGREE
Signature: / Date Submitted:
PER DIEM APPLICATION 06/12
OFFICE OF HUMAN CAPITAL INITIATIVES / 2012-2013 / SUBSTITUTE MANAGEMENT DIVISIONNAME:
/ Employee ID #:I am not interested in working as a Per Diem Substitute with the Rochester City School District for the 2012-2013 school year. I understand that my name will be removed from the Substitute Roster.
I am interested in working as a Per Diem Substitute with the Rochester City School District for the 2012-2013 school year. Please select one (1) area below:
Per Diem Teacher - Certified (T746)Please check certification status:
£ Initial £ Provisional £ Conditional £ Professional £ Permanent £ Transitional A, B, or C
Certification Area / Type / Effective Date
I am interested in working as a Building Per Diem teacher (must be certified and worked at least 50 days.)
Per Diem Teacher - Uncertified (T752)
I do not hold a NYS teaching certificate. I understand that I may substitute teach for up to 100 days since I am completing collegiate study toward certification at the rate of at least three (3) credit hours per semester.
I do not hold a NYS teaching certificate. I understand that I may substitute teach for up to 40 days per school year.
Per Diem Psychologist / Counselor / Speech (T746)
Please check certification status. Must have certification in one of the areas.
Initial Provisional Conditional Professional Permanent Transitional A, B, or C
Certification Area / Type / Effective Date
Per Diem Administrator (T748)
I am a retired RCSD administrator and a copy of my NYS administrative certification is on file in the Office of Human Capital Initiatives.
Per Diem Retiree (T751) / Test Corrector (T750)
I am a retired RCSD employee and a copy of my NYS teaching certification is on file in the Office of Human Capital Initiatives.
I am a retired RCSD employee ONLY interested in being a test corrector.
Per Diem Sentry (C473)
I am registered as a Security Guard and have been duly issued a license by the State of NY, Department of State, Division of Licensing Services.
License #: / Expiration Date:
PER DIEM APPLICATION 06/12
TEACHING CLASSIFICATIONS
£ / Art / T377£ / BILINGUAL (Must be able to speak and understand Spanish.) / T35
£ / Blind & Visually Impaired* / T719
£ / ELEMENTARY / T22
£ / English / T41
£ / ESOL* / T643
£ / Foreign Language / T469
£ / Health Education / T465
£ / Hearing Handicapped* / T717
£ / Home/Hospital Teacher* / T744
£ / Library Media Specialist / T390
£ / Mathematics / T59
£ / Music, Instrumental / T379
£ / Music, Vocal / T373
£ / Performing Arts / T371
£ / Physical Education / T375
£ / PRE-K / KINDERGARTEN* / T56
£ / School Attendance Teacher* / T482
£ / School Counselor* / T936
£ / School Instructor* / T745
£ / School Nurse* / T487
£ / School Psychologist* / T946
£ / School Social Worker* / T949
£ / Science / T474
£ / Social Studies / T475
£ / SPECIAL EDUCATION* / T86
£ / Speech/Language – Audiology – CAC* / T497
£ / Auto Body Repair / T476
£ / Auto Mechanics / T473
£ / Aviation/Transportation / T477
£ / Business/Marketing / T462
£ / Computer Science / T382
£ / Construction Trades / T488
£ / Cosmetology / T508
£ / Diversified Occupational Coop. / T516
£ / Electricity/Electronics Instruction / T490
£ / Family & Consumer Science / T468
£ / Graphic Arts Design / T496
£ / Instructional Computing / T381
£ / JROTC Officer / T54
£ / Mechanical Trades / T500
£ / Media Communications / T470
£ / Nursing / T487
£ / Printing Trades / T493
£ / School Instructional Nursing / T742
£ / Special Vocational Assessment / T708
£ / Technology / T380
£ / Vocational Education / T517
£ / Vocational Education – Food Preparation / T504
Please check your location preference(s):
£ / Al Locations (PreK-12, regular & special education)£ / Kindergarten – 12 (Special Education, ESOL)
£ / All Elementary Schools
£ / All Secondary Schools
Please check your workday preference(s).
£ / Monday£ / Tuesday
£ / Wednesday
£ / Thursday
£ / Friday
* Content Area Certification Required
PER DIEM APPLICATION 06/12