Employment Application

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING THE APPLICATION

Head Start, Inc. is an equal opportunity employer and does not discriminate in employment opportunities based upon race, color, national origin, age, physical or mental disability, marital status, religion, creed, sex, sexual orientation or political beliefs, except when there is a bona fide occupational qualification.

Interviews are given on a competitive basis, using job-related factors, after a written application has been received and reviewed. Because of the large number of applications received, not everyone who applies for a vacant position will be interviewed. I understand that completion of this employment application does not guarantee employment with Head Start, Inc.

I certify that I have answered truthfully and have not knowingly withheld any information relative to my application. I understand that any falsification, misrepresentation or any material omission on this application will result in my being eliminated from consideration for employment now and in the future. I further understand that, if accepted for employment, any falsification, misrepresentation or material omission which becomes known to Head Start, Inc. will result in immediate termination of my employment.

I authorize all previous employers and supervisors, including all persons with whom I have worked, to give Head Start, Inc. representatives any and all information regarding me and my previous employment. I release Head Start, Inc. and all employers and supervisors from liability for any damages that may result from furnishing information to Head Start, Inc.

I understand that, if selected, I will be required to pass a company paid physical exam and TB test and provide proof of my identity and my legal right to work in the United States prior to actual employment with Head Start, Inc.

In connection with my application for employment, I understand that an investigative consumer report will be conducted which may include information as to my work habits, performance, experience, education, credentials, references, driving record and criminal history. By signing below, I voluntarily and knowingly authorize Head Start, Inc. and/or its agents to verify any aspects of the information contained in my employment application or through public and private sources including federal, state, or local law enforcement agencies. I understand that any misrepresentation or any material omission on this application will result in my being eliminated from consideration for employment now and in the future. I further understand that, if accepted for employment, any misrepresentation or material omission which becomes known to Head Start, Inc. will result in immediate termination of my employment.

I, the undersigned Applicant, hereby authorize any private or public sources, including any federal, state or local law enforcement agency, having information concerning me, either public record or otherwise to release such information to Head Start, Inc and/or its agents. Further, I authorize any former employer, person, firm, corporation, school or government agency to release any and all information concerning my employment, to Head Start, Inc. and/or its agents.

I voluntarily and knowingly, fully release and discharge, absolve, indemnify and hold harmless, Head Start, Inc. and/or its agents, any former employer, person, firm, corporation, school or government agency from any and all liability or damages arising from the disclosure or release of any such information.

If hired, I understand this authorization shall remain on file and shall serve as an ongoing authorization for Head Start Inc. and/or its agents to procure a consumer report at any time during my employment period. I understand that I must provide my date of birth to adequately complete said background investigation, and acknowledge that my date of birth will not affect any hiring decisions.

Federal Head Start Administration regulations section 1301.31(b)(2) requires that all current and prospective employees of Head Start agencies sign a declaration which, at a minimum, lists:

1. All pending and prior criminal arrests and charges related to child sexual abuse and their disposition;
2. Convictions related to other forms of child abuse and/or neglect; and
3. All convictions of violent felonies.

The declarations may exclude:

1. Any traffic fines of $200.00 or less
2. Any offense, other than any offense related to child abuse and/or child sexual abuse or violent felonies, committed before the prospective employee’s 18th birthday which was finally adjudicated in a juvenile court or under a youth offender law;
3. Any conviction the record of which has been expunged under Federal or State law;
4. Any conviction set aside under the Federal Youth Corrections Act or similar State authority.

Falsification of this declaration is grounds for immediate disqualification from consideration for employment. Subsequent discovery that this declaration is false is grounds for immediate termination.

Note that individuals who declare that they have been arrested, charged with, or convicted of, any of the offenses listed above are not automatically disqualified from being hired. Head Start will review each case in order to assess the relevancy of an arrest, charge, or conviction prior to a hiring decision. Also note, in conformity with Federal Regulations, regardless of any other provisions concerning probationary employment, no position filled may be deemed regular employment until after examination of, and action on, the results of any criminal records check conducted pursuant to the employment process.

Each person employed by Head Start is under a continuing duty to report to the agency if he or she is ever arrested, charged, or convicted of any child sexual abuse offense(s) or is convicted of any other crimes, other than those exclusions as listed above.

Please provide your signature in the appropriate category below:

I have not been arrested, charged, and/or convicted on any of the offenses listed above.

I have been arrested, charged, and/or convicted on one or more of the offenses listed above.