Online Chaperone Application

Last Name:
First Name:
Middle Name:
Street Address:
City, State & Zip:
Phone:
Cell Phone:
Email: (REQ)
Social Security:
Date of Birth:
Driver's License State & Number:
Two Closest Airports:
Dates Available:
Referred By:
Have you ever been accused or convicted of a crime?	No Yes
Have you ever been accused or convicted of mishandling or misappropriating funds?	No Yes
Emergency Contact:
Address:
City State Zip:
Phone:
Cell:
Relationship:
EDUCATION & EXPERIENCE
EDUCATION	School: Dates Attended: Major Course of Study: Diploma/Degree: School: Dates Attended: Major Course of Study: Diploma/Degree: School: Dates Attended: Major Course of Study: Diploma/Degree:
Other educational experience/special skills (ie: First Aid, CPR, sign language):
Describe experience working with people with developmental disabilities:
Describe travel experience:
Volunteer experience:
EMPLOYMENT HISTORY
Current Employer:
Supervisor:
Job Title:
Brief Job Description:
Employment Start Date:	End Date:
Address, City, State, Zip:
Phone:
Reason for Leaving:
Previous Employer:
Supervisor:
Job Title:
Brief Job Description:
Employment Start Date:	End Date:
Address, City, State, Zip:
Phone:
Reason for Leaving:
Previous Employer:
Supervisor:
Job Title:
Brief Job Description:
Employment Start Date:	End Date:
Address, City, State, Zip:
Phone:
Reason for Leaving:
REFERENCES
Please list three people not related to you whom you have known for at least one year.
Name: Address: Relationship: Phone: Name: Address: Relationship: Phone: Name: Address: Relationship: Phone:
I state that all of the information provided above is true and accurate to the best of my knowledge. I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of facts is a Federal crime punishable by law.
Today's Date:
Your Name ("Signature"):
For office use only:
Date Received:
Contact: