SOMERS PUBLIC SCHOOLS

1 VISION BOULEVARD

SOMERS, CONNECTICUT 06071

APPLICATION FOR SUBSTITUTE TEACHING

Name: Date:

Social Security Number: - -

Please list any other name by which you have been known if that name will be necessary to verify your identity, employment history or educational background.

Street:

Town: State: Zip:

Home Telephone #: () - Cell #: () -

Other: () -

Email Address:

Are You a U.S. Citizen or Authorized to Work in the U.S.? Yes No Explain

Do You Hold a Current CT Teaching Certificate? Yes No

If Yes, please list areas of Endorsement:

Grade Level(s) You Are Willing to Teach: PreK-5 6-8 9-12

Subject Areas You Are Willing to Teach:

Days you are NOT available:

Are you Interested in Tutoring? Yes No

If Yes, What Subject(s)?

Please list any other information that would be useful to our Substitute Caller?

EDUCATION HISTORY

Name / Location / Degree /Date / Major
High School
College
Graduate
Other

Attach or bring to your interview copies of your resume, degrees and transcripts and CT Certification if applicable.

STUDENT TEACHING EXPERIENCE

From / To / School / Location / Grade/Subject(s)

WORK EXPERIENCE

From / To / Firm, Agency, etc. / Location / Position/Title / Years Employed

Have you been convicted of a crime, or are criminal charges currently pending, which have not been annulled, expunged or sealed by a court? Yes No

If yes, please describe in full.

All persons hired by the Somers Board of Education must submit to a state and national criminal records check within 30 days of being hired by the Somers Board of Education.

Have you been fingerprinted before? Yes No

If Yes, date AND where you were printed:

(CREC, EASTCONN, another school system, State/local police, etc.):

“Conviction” for this application, means a final judgment or verdict of guilty, pleas of guilty, or a plea of nolo contendere, in any state or federal court, regardless of whether an appeal is pending or could be taken. “Conviction” does not include a final judgment or verdict that has been expunged by pardon, reversed, set aside or otherwise rendered invalid. Further, you are not required to disclose any arrest(s), criminal charge(s) or conviction(s) the record(s) of which have been erased pursuant to Connecticut General Statutes §§ 46b-146, 54- 76o or 54-142a. Such records can include records of a finding of delinquency or that a child was a member of a family with service needs, adjudication of youthful offender status, criminal charges dismissed or nolled, or charges for which a person is found not guilty or a conviction later resulting in an absolute pardon. Further, any person whose criminal records have been erased is deemed under law never to have been arrested with respect to such erased proceedings and may so swear under oath. A history of criminal conviction(s) will not necessarily bar consideration of employment. Factors such as the time, seriousness and nature of the offense, as well as rehabilitation, will be taken into account.

REFERENCES: Give names of at least three individuals who have closely observed your work as a teacher, employee or student.

Name / Title / Address / Phone

APPLICANT’S ACKNOWLEDGEMENT AND AGREEMENT

By checking the box below, I hereby authorize and voluntarily release the Somers Public Schools to conduct any necessary inquiries and collect any necessary information as to my character, reputation, and ability to perform in the position I am applying for, including but not limited to my educational and employment references and background, my fingerprint and my criminal conviction history check. I release from any liability any and all former employers or educators, or personal or other references who supply the Somers Public Schools with information about my background, education or employment history.

I, , agree to all of the terms above. I agree

EQUAL OPPORTUNITY EMPLOYER

Non-Discrimination Statement: Revised 7/29/2016

The Somers Public Schools is committed to equal opportunity for all students, applicants and employees. The District does not discriminate in any employment practice, education program, or educational activity on the basis of race, color, religious creed, sex, age, national origin, ancestry, marital status, sexual orientation, gender identity or expression, disability (including, but not limited to, intellectual disability, past or present history of mental disorder, physical disability or learning disability), genetic information, or any other basis prohibited by Connecticut state and/or federal nondiscrimination laws. In addition, it provides equal access to the Boy Scouts and other designated youth groups. Inquiries regarding the District’s nondiscrimination policies should be directed to Dr. Irene Zytka, Title IX Coordinator, 1 Vision Boulevard, Somers, CT 06071, (860) 749-2270 x2039

Should an accommodation for a disability be required, please contact Dr. Denise Messina, Director of Pupil Services and Section 504 Coordinator, 1 Vision Boulevard, Somers, CT 06071, (860) 749-2270 x2052

Rev. 7/29/2016

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