Victory Tabernacle Child Development Center
11700 Genito Rd. Midlothian, Va 23112
OPEN HOUSE
SUMMER CAMP!
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NEW FOR 2012-2013
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First Name
Middle Name
Last Name
Address Line 1
City
State
Zip Code
Daytime Phone
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Evening Phone
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E-mail Address
Cell Phone
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Birthday
How Many Children?
Ages of Children?
Name of Your Church?
Do You Understand the Doctrine of the Church of God?
WIll You Be Able to Work Within the Church of God Belief Structure?
Have You Ever Applied to VTCDC?
Do You Have Friends or Relatives That Work at VTCDC?
Name of Current Employer?
Address of Employer
City of Employer
State of Employer
Phone Number of Employer
Hourly Rate Start and Finish
May We Contact Your Current Employer?
Name of Past Employer #1
Address of Past Employer #1
City of Past Employer #1
State of Past Employer #1
Phone Number of Past Employer #1
Hourly Ending Rate at Employer #1?
Name of Past Employer #2
Address of Past Employer #2
City of Past Employer #2
State of Past Employer #2
Phone Number of Past Employer #2
May We Contact Past Employer #2?
Hourly Ending Rate at Employer #2
Do You Have Any Physical, Mental, or Medical Impairment that would limit your job performance?
If you have any Limitations, Please explain
Are You Willing to Take Child Development Classes?
Are You Prevented From Lawfully Being Employed in the United States Because of Visa or Immigration Status?
Date Available for Work?
Your Desired Salary Range?
Are You Available Full-Time?
Are You Available Part-Time?
Name of High School and Highest Grade Completed
Name of College and Number of Years Completed
Major in College
Have you ever been convicted of a felony or a misdemeanor, or been involved with a child abuse or neglect court action offcial investigation? If yes, please explain.
Describe Any Specialized Training, Apprenticeship, Skills, and Extra-Curricular Activities
Name of Pastoral Reference
Address of Pastor
Phone of Pastor
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Name of Reference #2
Address of Reference #2
City of Reference #2
State of Reference #2
Telephone Number of Reference #2
Name of Reference #3
Address of Reference #3
City of Reference #3
State of Reference #3
Telephone of Reference #3
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Providing a Quality, Christian Education
11700 Genito Rd. Midlothian, Va 23112
804-744-8700 ext.226