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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

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