Coaching/Co-Curricular Application Form
by Kris Van Pelt
October 21, 2005
401.4 Exhibit H
BOARD OF DIRECTORS
OGDEN COMMUNITY SCHOOL DISTRICT
COACHING/CO-CURRICULAR APPLICATION FORM
1. Please complete all information and forward to:
Superintendent: Ogden Community School District
PO Box 250
Ogden, IA 50212
2. Personal letter of application.
3. Copy of Coaching Endorsement
PERSONAL INFORMATION
Last Name____________________First___________________Middle_______________
Business Address_____________________________________Telephone_____________
City_________________________State___________________Zip__________________
Home Address_______________________________________Telephone_____________
City________________________State___________________Zip____________________
Present Position____________________________________________________________
Are you under contract at the present time?______________________________________
Types of certification/licenses or authorizations held_______________________________
License/authorization No._____________________________________________________
Are you trained in first aid techniques?_____________Yes _________________No_______
Training____________________________________________________________________
Are you trained in CPR training?__________________Yes__________________No_______
Were you honorably discharged from the United States military forces after service between
the periods of December 7, 1941 and December 31, 1946, or June 25, 1950 to January 31,
1955, or August 5, 1964 to May 7, 1975, or during the Persian Gulf conflict?
_______________________Yes ______________________No
Please complete if you are claiming veteran's preference:
Active Duty/Reserve Duty
Branch____________________________ Period of Duty________________________
Location of Duty____________________Rank at Discharge______________________
Has there ever been a judicial or administrative finding that you have abused or mistreated a
minor or child? (If yes, attach explanation.) _______________Yes___________________No
EMPLOYMENT HISTORY
List all experience in chronological order.
NAME LOCATION POSITION FROM/TO SUPERVISOR PHONE
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
PROFESSIONAL PREPARATION
INSTITUTION LOCATION MAJOR/MINOR DEGREE
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
REFERENCE (LIST AT LEAST TWO)
NAME POSITION RES. PHONE BUS. PHONE
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
I certify that the information given in this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application, and I authorize Ogden Community School District to contact my references and prior employers, and release from all liability or responsibility all persons or corporations requesting or supplying information. I understand that giving false, incomplete, or misleading information in my application or interview may result in withdrawal of my application for consideration or in discharge.
I understand that the Ogden Community School District will do a criminal records and child abuse check on me.
If my duties will include driving a school vehicle for which I need a CDL license and if the vehicle transports 16 or more persons or the vehicle weights 26,001 pounds or more, I have been informed of the requirement to submit to a drug test prior to being employed by the District to perform a safety-sensitive function. I consent to submit to the District's drug and alcohol testing program. I also understand that if I have a positive drug test, I will not be considered further for employment by the District.
I UNDERSTAND THAT I MAY NOT BE EMPLOYED UNTIL APPROVAL IS GIVEN BY THE DISTRICT'S BOARD OF DIRECTORS.
Signed____________________________________________________Date____________________
The Ogden Community School District provides equal employment opportunities to all persons regardless of race, color, national origin, creed, religion, material status, age or disability. Questions regarding compliance with equal employment opportunities should be directed to the Superintendent at PO Box 250, Ogden, Iowa 50212, telephone number (515) 275-2894
