Sullivan County School District

SULLIVAN COUNTY SCHOOL DISTRICT

Richard Rogers, Athletic Director

749 South Street, PO Box 298

Laporte, PA 18626

Telephone: (570) 946-7001

Fax: (570) 946-4202

APPLICATION FOR EMPLOYMENT/VOLUNTEER

Applicant’s Name______Date______

LastFirst Middle

Address:

Street______

______

City, State, ZIP______

TelephoneHome: ______Cell: ______

Email______

Application for Position(s):

Head Coach – Sport______

Assistant Coach – Sport ______

Volunteer Coach – Sport ______

Elementary Coach – Sport ______

Advisor – Activity ______

Please submit all required paperwork with the application and indicate the status below.

Clearances:Have CurrentHave Applied

(Dated within 1 year)

Act 34 PA State Police______

Act 114 FBI Fingerprint______

Act 151 Child Abuse______

Certifications:

CPR/AED Certification______

First Aid Certification______

Concussion Management Certification______

Sudden Cardiac Arrest Certification______

Other:

TB Test/Results______

PDE 6004 Arrest/Conviction Report ______

REFERENCES

These should be previous employers or persons qualified to respond concerning your fitness for the position you seek. Indicate any who are related to you.

NameAddressTelephoneOccupation

1.______

2.______

3.______

“An Equal Opportunity Employer”

EDUCATION

Name & AddressDate Graduated

High School______

College or

University______

Technical

School______

EMPLOYMENT HISTORY

Dates Employed

EmployerFromToWork Performed

______

Address

______

Hourly Rate/Salary

Telephone Number(s)StartingFinal

______

Job TitleSupervisor

______

Reason for Leaving______

Dates Employed

EmployerFromToWork Performed

______

Address

______

Hourly Rate/Salary

Telephone Number(s)StartingFinal

______

Job TitleSupervisor

______

Reason for Leaving______

May we contact the employers listed above?_____ If not, indicate which one(s) you do not wish us to contact______.

I hereby certify that all statements made in this application are true and complete. I understand that any false or misleading statement on this application constitutes sufficient grounds for dismissal if hired. In addition, in making this application for employment, I understand that the Sullivan County School District may investigate my employment record. I hereby authorize my current and/or former employer(s) to furnish the information requested by the Sullivan County School District.

Signature______Date______

GENERAL BACKGROUND INFORMATION

You must give complete answers to all questions. If you answer “Yes” to any question, you must list all offenses, and for each conviction provide date of conviction and disposition, regardless of the date or location of occurrence. Conviction of a criminal offense is not a bar to employment in all cases. Each case is considered on its merits. Your answers will be verified with appropriate police records.

Criminal Offense includes felonies, misdemeanors, summary offenses and conviction resulting from a plea of “nolo contendere” (no contest).

Conviction is an adjudication of guilt and includes determinations before a court, a district justice or a magistrate, which results in a fine, sentence or probation.

You may omit: minor traffic violations, offenses committed before your 18th birthday which were adjudicated in juvenile court or under a Youth Offender Law, and any convictions which have been expunged by a court or for which you successfully completed an Accelerated Rehabilitative Disposition program.

Were you ever convicted of a criminal offense?□ Yes□ No

Are you currently under charges for a criminal offense?□ Yes□ No

Have you ever forfeited bond or collateral in connection with a criminal offense?□ Yes□ No

Within the last ten years, have you been fired from any job for any reason?□ Yes□ No

Within the last ten years, have you quit a job after being notified that you would□ Yes□ No
be fired?

Have you ever been professionally disciplined in any state?□ Yes□ No

Professionally disciplined means the annulment, revocation or suspension of

your teaching certification or having received a letter of reprimand from an agency,

board or commission of state government, such as the Pennsylvania Professional

Standards and Practices Commission.

Are you subject to any visa or immigration status, which would prevent lawful□ Yes□ No
employment?

Note: If you answered “Yes” to any of the above questions, please provide a detailed explanation on a separate sheet of paper, including dates, and attach it to this application. Please print and sign your name on the sheet and include your social security number.

“An Equal Opportunity Employer”

Thank you for your interest in

Sullivan County School District Athletics.

Following is a list of required paperwork, clearances and

certifications with information on where to find the forms,

fees-if any, and other relevant information.

All of the required paperwork must be submitted along with

your completed application to be considered for approval by the

Sullivan County Board of School Directors.

Completed Application

Application is attached

Act 34 PA State Police Clearance

Application is attachedor for online registration go to click on “Codes and Regulations” and follow instructions.

$10.00

Act 114 FBI Fingerprint Clearance

click on “Codes and Regulations” and follow instructions.

(Be sure to click on the PDE icon when registering for this clearance)

$28.75

Act 151 Child Abuse Clearance

Application is attached. More information is available at

$10.00

CPR/AED Certification

You must hold current CPR/AED certification that does not expire until after your sports season ends. A free course will be offered at the high school the first week in November and third week in February, annually.

First Aid Certification

You must hold current First Aid certification that does not expire until after your sports season ends. A free course will be offered at the high school the first week in November and third week in February, annually.