ࡱ> sulmnopqrq` bjbjqPqP 4::6S((((TBBBPCtDёlF OOOOS0M[\_0{~}~}~}~=~J$hngR|Sggn((OOnnngv(ROO{~ng{~nnVKv@z"wO`F |Bgv w0ёvxhww#wa,cncdaaannyn^aaaёggggd7T>dT>((((((  APPLICATION FOR EMPLOYMENT  Thank you for your interest in the Sacramento Childrens Home. The job specifications for each position vacancy are located in the Human Resources Department for your review and are also available on our website at  HYPERLINK "http://www.kidshome.org" www.kidshome.org. Please ensure that you meet the minimum requirements of the job so your application may be processed expediently. Please indicate the title of the position you are applying for. Only completed applications for open positions will be accepted as long as the minimum requirements of the position are met. If you have a resume, please include it with your application. You will be contacted by phone if you meet the qualifications of the job and the hiring manager wishes to schedule an interview. Our managers prefer you do not contact them directly regarding vacancies unless you have been selected for an interview. Positions may require a good DMV record. Positions may require a valid California Driver License. Positions may require that you be at least 21 years of age. Positions may require that you have personal auto insurance. All positions require that you have a high school diploma or GED. All applicants can not begin work until clearances have been received for all pre-employment requirements. All job offers are contingent upon clearance of all pre-employment requirements which includes; fingerprint criminal records check, employment history and education verification, DMV records, drug test, physical exam, and TB test. Please note: As part of the employment process you will be required to complete a Criminal Records Statement from the CA Dept of Social Services, CCL Division -form LIC 508 (1/03). Do not disclose any misdemeanor marijuana-related conviction that is more than 2 years old. However, any felony marijuana-related conviction must be disclosed, regardless of time. Residential Counselor positions require availability to attend weekly meetings every Wednesday and availability to work nights, weekends and holidays. This is a requirement of the position and thus no exceptions can be made. There may be other requirements for positions that you will find on the job announcement, our website, and/or on the job description. Thank you again for your interest in the Sacramento Childrens Home.  Dear Applicant, Thank you for your interest in the Sacramento Children's Home. Please respond to the following minimum requirements only if you are applying for a Residential Counselor position on campus or in the Group Homes: YES NO 1. You must be available every Wednesday for team meetings. No exceptions. You must be available evenings and  FORMCHECKBOX   FORMCHECKBOX  weekends and available for on-call shifts. You must be 21 years of age or older and have a high school diploma or GED.  FORMCHECKBOX   FORMCHECKBOX  3. You may be required to drive your personal auto on agency business. A. Do you have a vehicle?  FORMCHECKBOX   FORMCHECKBOX  B. Do you have the minimum amount of auto insurance prescribed by state law ($15/30,000 bodily injury & $5,000 property damage)?  FORMCHECKBOX   FORMCHECKBOX  If answer is no to questions 1 or 2 of the above STOP HERE. You do not meet the minimum requirements. If you answered yes, please finish completing this form. I am not available to work the following hours: SundayMondayTuesdayWednesdayThursdayFridaySaturday FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       My current school schedule is: SundayMondayTuesdayWednesdayThursdayFridaySaturday FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       I verify that the above information is true and correct. ___ FORMTEXT      ___________________________ __ FORMTEXT      ____________ Signature Date Completed Form 508 (attached) must be submitted with application. Fingerprints required upon hire. Please complete the entire application. Any missing information will cause your application to be rejected. Provide all names, addresses and dates of employment where required. If your application has been selected for an interview, you will be notified by phone. PLEASE DO NOT CALL. Sacramento Childrens Home 2750 Sutterville Road, Sacramento, CA 95820 Fax: (866) 659-6866 PERSONAL INFORMATION Last Name First Name Middle  FORMTEXT        FORMTEXT        FORMTEXT      Date  FORMTEXT      Street Address  FORMTEXT      Home Telephone ( FORMTEXT    ) FORMTEXT      City, State, Zip  FORMTEXT      Business Telephone ( FORMTEXT    ) FORMTEXT      Have you ever applied for employment with us?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Have you ever been employed with us?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If you answered yes to either question, state when and where you applied and/ worked?  FORMTEXT      How did you learn about our company/position?  FORMDROPDOWN  If referred by current employee of SCH, indicate name of the employee.  FORMTEXT      Position Desired:  FORMTEXT      Pay Desired:  FORMTEXT      Are you seeking:  FORMCHECKBOX  Full-time  FORMCHECKBOX  Part-time  FORMCHECKBOX  Temporary or summer employmentWhen will you be available to begin work?  FORMTEXT      Are you legally eligible for employment in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No EDUCATION SchoolName and Address of SchoolCourse of Study# of Years CompletedDid you Graduate?Degree or DiplomaHigh School   FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      College   FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Business/ Trade/ Technical  FORMTEXT        FORMTEXT        FORMTEXT        FORMDROPDOWN   FORMTEXT      Other   FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Special Skills and Training  FORMTEXT       Use this space below to describe why you are interested in working for the Sacramento Children s Home and to list those skills and abilities that you feel particularly qualify you for a position with us. If you need more space, please continue on a separate sheet.  FORMTEXT       EMPLOYMENT HISTORY Please list your last three employers, starting with present. Please attach your resume if additional positions were held. Company Name: FORMTEXT      Telephone Number: ( FORMTEXT    ) FORMTEXT      Address:  FORMTEXT      Dates of Employment (State Month and Year): From  FORMTEXT       To  FORMTEXT       Hrs per wk:  FORMTEXT      Name and Title of Last Supervisor:  FORMTEXT      Salary: $  FORMTEXT       per  FORMTEXT      State Job Title and Describe Your Work:  FORMTEXT      Reason for Leaving: FORMTEXT      May we contact this employer? FORMDROPDOWN  Company Name: FORMTEXT      Telephone Number: ( FORMTEXT     ) FORMTEXT      Address:  FORMTEXT      Dates of Employment (State Month and Year): From  FORMTEXT       To  FORMTEXT       Hrs per wk: FORMTEXT      Name and Title of Last Supervisor:  FORMTEXT      Salary: $  FORMTEXT       per  FORMTEXT      State Job Title and Describe Your Work:  FORMTEXT      Reason for Leaving: FORMTEXT      May we contact this employer? FORMDROPDOWN  Company Name: FORMTEXT      Telephone Number: ( FORMTEXT    ) FORMTEXT      Address:  FORMTEXT      Dates of Employment (State Month and Year): From  FORMTEXT       To  FORMTEXT       Hrs per wk: FORMTEXT      Name and Title of Last Supervisor:  FORMTEXT      Salary: $  FORMTEXT       per  FORMTEXT      State Job Title and Describe Your Work:  FORMTEXT      Reason for Leaving: FORMTEXT      May we contact this employer? FORMDROPDOWN  EMPLOYMENT REFERENCES Give the names of three persons who have previously supervised your work. NameAddressPhone Number Years Acquainted FORMTEXT       FORMTEXT      ( FORMTEXT    ) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      ( FORMTEXT    ) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      ( FORMTEXT    ) FORMTEXT       FORMTEXT       APPLICANT SIGNATURE: I certify that answers given herein are true and complete to the best of my knowledge. I I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an at will nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. 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with licensed facilities be fingerprinted and disclose any conviction. A conviction is any plea of guilty or nolo contendere (no contest) or a verdict of guilty. The fingerprints will be used to obtain a copy of any criminal history you may have.  Have you ever been convicted of a crime in California? . . . . . . . . . . . . . . . . . . . . . . . . . . . .  FORMCHECKBOX  YES  FORMCHECKBOX  NO Have you ever been convicted of a crime from another state, federal court, military or jurisdiction outside of U.S.? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FORMCHECKBOX  YES  FORMCHECKBOX  NO Criminal convictions from another State or Federal court are considered the same as criminal convictions in California. If you answer YES, give details on the back of this page indicating the nature and circumstances of each crime and the date and the location in which each crime occurred. You must disclose convictions, including reckless and drunk driving convictions even if: 1. It happened a long time ago; 2. It was only a misdemeanor; 3. You didn t have to go to court (your attorney went for you); 4. You had no jail time or the sentence was only a fine or probation; 5. You received a certificate of rehabilitation; 6. The conviction was later dismissed, set aside or the sentence was suspended. NOTE: IF THE CRIMINAL BACKGROUND CHECK REVEALS ANY CONVICTION(S) THAT YOU DID NOT DISCLOSE ON THIS FORM, YOUR FAILURE TO DISCLOSE THE CONVICTION(S) WILL RESULT IN AN EXEMPTION DENIAL, LICENSE APPLICATION DENIAL, LICENSE REVOCATION, OR EXCLUSION FROM A LICENSED FACILITY. I declare under penalty of perjury under the laws of the State of California that I have read and understand the information contained in this affidavit and that my responses and any accompanying attachments are true and correct.FACILITY NAME Sacramento Children s HomeFACILITY NUMBERYOUR NAME (PRINT CLEARLY)  FORMTEXT      YOUR ADDRESS  FORMTEXT      CITY  FORMTEXT      ZIP  FORMTEXT      SIGNATURE  FORMTEXT      DATE  FORMTEXT       I. Instructions to Respondents: If you have been convicted of a crime in California or from another state or in federal court, provide the following information: What was the offense?______________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ In which state and city did you commit the offense? _____________________________________________ __________________________________________________________________________________________ When did this occur? _______________________________________________________________________ Tell us what happened. (Use additional sheets of paper if needed) ________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ I certify under penalty of perjury that the above information is true and correct to the best of my knowledge. Signature _________________________________________________ Date __________________________ II. Instructions to Licensees: If the person discloses a criminal conviction, review the person s statement and discuss it with your Licensing Program Analyst (LPA). Maintain this form in your facility personnel file and send a copy to your LPA.       PAGE 6 PRIVACY STATEMENT Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code section 1798 et seq.), notice is given for the request of the Social Security Number (SSN) on this form. The California Department of Justice uses a person s SSN as an identifying number. The requested SSN is voluntary. Failure to provide the SSN may delay the processing of this form and the criminal record check. In order to be licensed, work at, or be present in, a licensed facility, the law requires that you complete a criminal background check. (Health and Safety Code sections 1522, 1568.09, 1569.17, and 1596.871.) The Department will create a file concerning your criminal background check that will contain certain documents, including information that you provide. You have the right to access certain records containing your personal information maintained by the Department (Civil Code 1798 et seq.). Under the California Public Records Act, the Department may have to provide copies of some of the records in the file to members of the public who ask for them, including newspaper and television reporters. NOTE: IMPORTANT INFORMATION The Department is required to tell people who ask, including the press, if some one in a licensed facility has a criminal record exemption. The Department must also tell people who ask, the name of the facility that has a licensee, employee, resident, or other person with a criminal record exemption. If you have any questions about this form, please contact your local licensing regional office. 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