Coulee-Hartline School District #151
Coulee-Hartline School District #151 District Office 509-632-8642
410 W. Locust - PO Box 428 District FAX 509-632-5166
Coulee City, WA 99115
Dear Applicant:
Thank you for your interest in a position with the Coulee-Hartline School District. Please complete the enclosed application materials and return them to me with a letter of application, a complete and current resume, copies of your teaching and administrator certificates, and copies of your college/university transcripts. Also, please send three letters of reference or a college/university placement file.
Your letter should include an explanation of why you are interested in an administrative position with the Coulee-Hartline School District, any special skills or abilities that you will bring to this position, and your thoughts about how to build staff unity in a high school building.
Your resume should include detailed information about your education, your work history, and a list of references who are familiar with you in an educational or work setting.
The deadline for the receipt of the complete application package is listed on the job announcement and interviews will be scheduled as soon as possible. We will call you if you are a finalist to be interviewed.
Thanks again for your interest in the Coulee-Hartline School District. I am looking forward to receiving your application.
Sincerely,
Edward A. Fisk, Ed.D.
Superintendent
Enclosures
APPLICATION FOR CERTIFICATED EMPLOYMENT
Equal Opportunity Employer
COULEE-HARTLINE SCHOOL DISTRICT #151
PO Box 428
Coulee City, WA 99115
FULL NAME ______DATE ______
Last First Middle
WASH. CERTIFICATION NO. ______
RETIREMENT INFORMATION
___ I am not a member of the retirement system in the state of Washington.
___ I am currently a member of the ______retirement system in the state of Washington. (Plan No. ___)
___ I was previously a member of the ______retirement system in the state of Washington until I separated employment on ______.
CONTRIBUTIONS REFUNDED? ___ Yes ___ No
PERSONAL INFORMATION
OTHER NAME(S) UNDER WHICH RECORDS MAY BE LISTED ______
PRESENT ADDRESS ______
AND TELEPHONE ______
______
PERMANENT ADDRESS ______
AND TELEPHONE ______
(if different than above) ______
PERSON THROUGH WHOM YOU MAY BE REACHED ______Telephone ______
PRESENT EMPLOYMENT POSITION ______
Telephone ______
DATE ABLE TO INITIATE SERVICE ______
Name, relationship and position of relatives now working for Coulee-Hartline School District: ______
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SIGNATURE RELEASE
All of the information I have provided in this application is true, correct and complete. I authorize Coulee-Hartline School District No. 151 to inquire with former employers or references and obtain any and all information regarding my job-related background. I release and waive Coulee-Hartline School District No. 151, my former employer, and all references from any and all liability in obtaining or disclosing such information. I agree that if I have provided false or incomplete statements, the district, may at its sole discretion, without notice or due process procedures, terminate my employment contract. If such action is taken by the district, the contract shall be deemed void from its inception.
______
Signature of Applicant Date
OPTIONAL INFORMATION
Name ______Date ______
RACE/ETHNIC DESIGNATION: Please indicate your ethnic background.
____American Indian ____Black ____Hispanic ____Asian ____Caucasian
HANDICAP:
For the purpose of affirmative action, do you consider yourself to be handicapped/disabled? (Definition of handicapped for affirmative action includes persons with physical, sensory, or mental impairments that would impede obtaining and maintaining permanent employment and promotional opportunities. The impairments must be significant and permanent.) ___No____Yes
If yes, please explain______
Information regarding race and handicapping condition is for the purpose of corrective employment and to prevent discrimination. This information will be confidential.
EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
Coulee-Hartline School District #151
PO Box 428
Coulee City, WA 99115
(509) 632-8642
COULEE-HARTLINE SCHOOL DISTRICT NO. 151
APPLICANT DISCLOSURE FORM PURSUANT TO CHAPTER 486, LAWS OF 1987
Answer YES or NO to each listed item. If the answer is YES to any item, explain in the area provided indicating the charge or finding, the date, and the court(s) involved.
1. Have you ever been convicted of any crimes against persons as defined in Section 1 of Chapter 486, Laws of 1987, and listed as follows: Aggravated murder; first or second degree kidnapping; first, second, or third degree assault; first, second, or third degree rape; first, second, or third degree statutory rape; first or second degree robbery; first degree arson; first degree burglary; first or second degree manslaughter; first or second degree extortion; indecent liberties; incest; vehicular homicide; first degree promoting prostitution; communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of minors; first or second degree criminal mistreatment?
ANSWER______IF YES, EXPLAIN BELOW.
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2. Have you ever been found in any dependency action under RCW 13.34.030(2)(b) to have sexually assaulted or exploited any minor or to have physically abused any minor?
ANSWER______IF YES, EXPLAIN BELOW.
______
3. Have you ever been found by a court in a domestic relations proceeding under Title 26 RCW to have sexually abused or exploited any minor or to have physically abused any minor?
ANSWER______IF YES, EXPLAIN BELOW.
______
4. Have you ever been found in any disciplinary board final decision to have sexually abused or exploited any minor or to have physically abused any minor?
ANSWER______IF YES, EXPLAIN BELOW.
______
Pursuant to RCW 9A.72.085, I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.
Applicant Signature ______
Date and place ______
Witness ______
Business or Organization ______
Address ______State______Zip______
COULEE-HARTLINE SCHOOL DISTRICT NO. 151
PLEASE LIST AND DESCRIBE ANY PREVIOUS INJURIES WHICH YOU HAVE SUSTAINED REQUIRING MEDICAL TREATMENT FOR 30 DAYS OR LONGER.
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PLEASE LIST AND DESCRIBE ANY PRIOR WORKER'S COMPENSATION CLAIMS YOU HAVE FILED.
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______
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NAME (PLEASE PRINT)
______
SIGNATURE
______
DATE
COULEE-HARTLINE SCHOOL DISTRICT NO. 151
DISCRIMINATION PROHIBITED
In compliance with federal and state regulations, the following is published for your information:
Coulee-Hartline School District No. 151 requires that its faculty, administration and staff comply with the spirit and law of equal opportunity and nondiscrimination. Individuals having responsibility for admitting students, employing faculty and staff, and administering educational programs and activities are required to comply with the districts' policies and applicable state and federal laws that prohibit discrimination, to include but not be limited to:
1. RCW Chapter 49.60 - State of Washington, Law Against Discrimination, RCW Chapter 49.60 prohibits discrimination because of race, creed, color, national origin, sex, martial status, age or the presence of any sensory, mental or physical handicap.
2. Title VI of the Civil Rights Act of 1964 prohibits discrimination against students on the basis of race, color, or national origin in the operation of any federally-assisted program.
3. Title VII of the Civil Rights Act of 1964, as amended by the Equal Employment Opportunity Act, 1972, prohibits discrimination in employment on the basis of race, color, sex, religion, or national origin.
4. Regulations implementing Title IX of the Education Amendments of 1972 states:
". . . No person shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any academic, extracurricular, research, occupational training, or other education program or activity operated by a recipient which receives or benefits from federal financial assistance.
5. WAC Chapter 392-190, Equal Education Opportunity--Sex Discrimination Prohibited. This state law prohibits any public school district from discriminating on the basis of sex
with regard to any activity conducted by or in behalf of a school district, including but not limited to, preschool, adult education, community education, and vocational-technical program activities.
6. Regulations implementing Section 504 of the Rehabilitation Act of 1973 prohibits discrimination on the basis of handicap in any program or activity which receives or benefits from federal financial assistance.
Persons having special concerns in this regard should contact Dr. Edward Fisk, Superintendent for Coulee-Hartline School District #151, PO Box 428, Coulee City, WA 99115, telephone number (509) 632-5231 or 632-8642. The superintendent coordinates the equal opportunity compliance efforts for the district.