Respite Care of San Antonio, Inc. 605 Belknap Pl. / P.O. Box 12633 San Antonio, TX 78212 (210) 737-1212/ Fax (210) 737-1221 www.respitecaresa.org NOTICE TO APPLICANTS (PLEASE READ CAREFULLY): Respite Care of San Antonio, Inc. (RCSA) is a private not-forprofit agency serving persons with developmental disabilities under licenses from State Regulatory Authorities. Under these regulations RCSA is required to conduct criminal conviction checks before an offer of employment. Therefore, any offer of employment resulting from this application is considered temporary, pending the results of a criminal conviction check. Also, please note: You must answer every question completely. Questions not applicable may be answered N/A or none. Applications are not valid without the signature of the applicant. Employment at Respite Care of San Antonio, Inc. and any of its departments and locations shall be considered employment-at-will in which either employer or employee may terminate the employment relationship for any reason or no reason at all. Position applying for: Name: Social Security #: Last First Middle Present Address: Previous Address: Street/City/State/Zip Code Street/City/State/Zip Code Telephone #: Alternate #: Contact person at alternate phone Are you prevented from lawfully becoming employed in this country because of visa or immigration status?... Yes Are you 21 or older?... Yes Have you ever been employed by RCSA before... Yes If yes, please give dates and locations How were you referred to RCSA? Are you currently employed?... Yes Why do you want to work for RCSA?: Have you ever been convicted of any felony or misdemeanor?... Yes Have you ever entered a plea of guilty or no contest or are currently on probation or have ever received deferred adjudication for any felony or misdemeanor?... Yes Do you currently have any criminal charges pending against you... Yes If yes, please explain: (te: a yes will not necessarily result in disqualification for employment) Respite Care of San Antonio, Inc. is an equal opportunity employer. RCSA is committed to the goals of equal employment and will not unlawfully discriminate on the basis of race, color, creed, religion, pregnancy, sex, age, national origin, disability, veteran status, or marital status.
EDUCATIONAL BACKGROUND Name and Location Years Completed Did You Graduate? Course of Study High School G.E.D City, State College City, State Other City, State Summarize additional training (e.g., in-company courses, military schools, correspondence course, etc.): Special licenses or certificates you possess: List any special skills or qualification you possess: If you worked during high school and college, indicate types of jobs you held: In what high school/college extra curricular activities did you participate? Scholarships, academic honors won: DEVELOPMENTAL DISABILITY EXPERIENCE Please indicate any experience you have had with children with disabilities. Location / Position From To Responsibilities Location / Position From To Responsibilities
EMPLOYMENT HISTORY List the last 10 years of employment history starting with the most recent. Verification of three professional references is required. Employer Telephone Dates Employed ( ) Address From: / / To: / /. Summarize the nature of the work performed and job responsibilities Job Title Starting Immediate Supervisor and Title $ Per. Reason for Leaving Ending May we contact for reference? Yes $ Per. Employer Telephone Dates Employed ( ) Address From: / / To: / /. Summarize the nature of the work performed and job responsibilities Job Title Starting Immediate Supervisor and Title $ Per. Reason for Leaving Ending May we contact for reference? Yes $ Per. Employer Telephone Dates Employed ( ) Address From: / / To: / /. Summarize the nature of the work performed and job responsibilities Job Title Starting Immediate Supervisor and Title $ Per. Reason for Leaving Ending May we contact for reference? Yes $ Per. Employer Telephone Dates Employed ( ) Address From: / / To: / /. Summarize the nature of the work performed and job responsibilities Job Title Starting Immediate Supervisor and Title $ Per. Reason for Leaving Ending May we contact for reference? Yes $ Per.
Will you receive a satisfactory reference from your current and all previous employers? Yes If no, please explain. Have you ever been discharged or asked to resign by an employer? Yes If yes, please explain. Comments (including explanation of any gaps in employment): Driving is a requirement of work with RCSA. Exceptions may be granted by the COO. Do you have a valid driver s license?... Yes If yes, what state? Are you 21 or older?... Yes Do you have a clear driving record?... Yes Respite Care of San Antonio, Inc. will conduct a Motor Vehicle Registration check for all applicants and/or employees who will be a driver for RCSA. I hereby authorize Respite Care of San Antonio, Inc. to check and verify all statements obtained in this application. I further understand that any misrepresentation or omission of facts presented in this application for employment may result in my not being hired, or, if hired, may result in my dismissal. I understand and agree that if I am employed; my employment will be for an indefinite period of time. I have received no promises or guarantees as to how long RCSA will employ me. I understand and agree that if employed, I can quit at any time for any reason or no reason at all and that my employment may be terminated by RCSA at any time for any reason or no reason at all. The application is current for only 60 days. If at the end of this time I still wish to be considered for employment, it will be necessary for me to complete a new application. Signature Date How did you find us? ( ) Walk-in ( ) College Placement Office ( ) Texas Workforce Commission ( ) I am a former RCSA Employee ( ) Referred by a current RCSA employee ( ) Express News Newspaper ( ) Referred by a former RCSA employee ( ) Internet, RCSA Website ( ) Other:
Respite Care of San Antonio, Inc. Additional Applicant Information Application For Employment Addendum Applicant Name: (Please Print) Please list your addresses in the past 5 years (include Apt Number, City, State and Zip Code): 1. 2. 3. 4. What has prepared you for the position for which you are currently applying? Personal References Name & Relationship (circle one) Address (City, State, Zip Code) Daytime Phone Number How long have you known this person? Friend / Family/ Coworker Friend / Family/ Coworker Friend / Family/ Coworker Volunteer Experience Organization Duties and Time Frame Contact Person and Phone Number (optional) Have you ever been accused of physically, sexually or emotionally abusing a child or an adult? ( ) Yes ( ) If yes, please explain
Applicant Availability APPLICANT NAME: DATE: I would be available to work (check all that apply): Mornings 7 AM- 3 PM Mornings (summer only) 8 AM - 4 PM Mornings (daycare) 7:15 AM -4:15 PM Mornings (daycare) 9 AM - 6 PM Mornings (daycare) 7:15 AM - 1 PM Afternoon (daycare) 1 PM- 6 PM Afternoon 3 PM - 11 PM Afternoon 4 PM- 12 PM Afternoon 3 PM- 8:45 PM Overnight 11 PM- 7 AM Overnight 12 PM- 8 AM Weekends 8 AM 8 PM Weekends (overnight) 8PM 8AM Saturday (FDO) 9 AM 4 PM Monday and Wednesday (MDO) 8:30 AM 4:30 PM Friday or Saturday Night (PNO) 6:30 PM 10:30PM (te: Majority of the direct care shifts includes weekends) Monday through Friday (administration only) 8:30AM-5 PM Days Available: Sunday Monday Tuesday Wednesday Thursday Friday Saturday I am interested in working (check all that apply): Full Time Part Time Substitute 40 hours week 0 29 hours week As Needed Minimum 16 hrs. per pay period Location I am available to work at (check all that apply): 605 Belknap Place (Central San Antonio- rth of San Antonio College) Main Office All applications Training Site 605 Belknap Place (Central San Antonio- rth of San Antonio College) Davidson Respite House/Najim Respite House Emergency Shelter Christ Episcopal Church 303 W. French Place (Central San Antonio- rth of San Antonio College) Respite Daycare / Family Day Out ARC (Pam Stephens Center) 6530 Wurzbach Family Day Out 1303 Tampico Mother s Day Out
* Complete upon submission with RCSA screener. Respite Care of San Antonio, Inc. Consent for request of Criminal History/Employment/DMV/FBI Fingerprint Request is made for any record of background history found in the files of the Texas Department of Public Safety (DPS) centralized criminal history record information system regarding the person identified herein. This information will be released to: Respite Care of San Antonio, Inc., P.O. Box 12633 / 605 Belknap Place, San Antonio, TX 78212 Agency Name and Address ACKNOWLEDGMENT BY APPLICANT I have applied for a position with the above stated organization. I know I have the right to inspect my criminal history record and to request correction of any inaccurate information. I understand that in connection with the application process, Respite Care of San Antonio, Inc._ will conduct a background check on me. The information provided by me will be the basis for the search of public records, which may include, but not be limited to, a search for criminal arrests/convictions, FBI fingerprint check, past employment, department of motor vehicle records, education confirmation, and drug test. APPLICANT INFORMATION Please print Name:. Last First Middle Maiden Address:. Street City State Zip SEX. RACE DATE OF BIRTH. SOC SEC NO. Phone# Driver s License/ID# State Issuing DL/ID My signature below indicates I have carefully read and understand this notice and consent to the release of criminal history records to Respite Care of San Antonio, Inc. for employment purposes. I agree that I have not been convicted of any felony and/or misdemeanor the preceding 10 years and there are no criminal charges pending against me. Do not sign below if you have been convicted of a felony and/or misdemeanor and there are criminal charges pending against you. Applicant s Signature/Consent.. Date
* Complete upon submission with RCSA screener. AFFIDAVIT FOR APPLICANTS FOR EMPLOYMENT WITH A LICENSED OPERATION OR REGISTERED CHILD-CARE HOME AN APPLICANT FOR TEMPORARY OR PERMANENT EMPLOYMENT with a licensed child-care facility, licensed child-placing agency or registered child-care home whose employment or potential employment with the facility, agency, or home involves direct interaction with or the opportunity to interact and associate with children must execute and submit the following affidavit with the application for employment: STATE OF COUNTY OF Texas Bexar I swear or affirm under penalty of perjury that I do not now and I have not at any time, either as an adult or as a juvenile: 1. Been convicted of; 2. Pleaded guilty to (whether or not resulting in a conviction); 3. Pleaded nolo contendere or no contest to; 4. Admitted; 5. Had any judgment or order rendered against me (whether by default or otherwise); 6. Entered into any settlement of an action or claim of; 7. Had any license, certification, employment, or volunteer position suspended, revoked, terminated, or adversely affected because of; 8. Resigned under threat of termination of employment or volunteerism for; 9. Had a report of child abuse or neglect made and substantiated against me for; or 10. Have any pending criminal charges against me in this or any other jurisdiction for; Any conduct, matter, or thing (irrespective of formal name thereof) constituting or involving (whether under criminal or civil law of any jurisdiction): 1. Any felony; 2. Rape or other sexual assault; 3. Physical, sexual, emotional abuse and/or neglect of a minor; 4. Incest; 5. Exploitation, including sexual, of a minor; 6. Sexual misconduct with a minor; 7. Molestation of a child; 8. Lewdness or indecent exposure; 9. Lewd and lascivious behavior; 10. Obscene or pornographic literature, photographs, or videos; 11. Assault, battery, or any violent offense involving a minor; 12. Endangerment of a child; 13. Any misdemeanor or other offense classification involving a minor or to which a minor was a witness; 14. Unfitness as a parent or custodian; 15. Removing children from a state or concealing children in violation of a court order; 16. Restrictions or limitations on contact or visitation with children or minors resulting from a court order protecting a child or minor from abuse, neglect, or exploitation; or, 17. Any type of child abduction. Except the following (list all incidents, locations, description, and date) (if none, write NONE) The failure or refusal of the applicant to sign or provide the affidavit constitutes good cause for refusal to hire the applicant. Signed: Date: Subscribed and sworn to (or affirmed) before me this day of Signature of notary officer: (seal, if any, of notarial officer) My commission expires: