Personal Info:

Name: (Last, First, MI)

Email Address:

Telephone Number

Social Security Number:

Gender:

 Male     Female

Are you 18 or Older?

 Yes     No

School Address:

City, State, Zip

Date of Application:

Preferred Name:

Permanent Address:

City, State, Zip:

Telephone:

Educational Background:

High School Diploma from:

College or University:

Major:

Current Year in School or highest level attained:

Undergraduate  1  2  3  4

Graduate/Professional school   1  2  3  4

Area of Professional Interest

Please list any relevant workshops and seminars you have attended:

Check any certifications and/or special training you have:

 First Aid Certificate   CPR Certified   Water Safety Instructor
 Advanced Lifesaving

Work & Volunteer Experience:
 (Note experience with people with disabilities)

Employer

Job Title

Date of Employment

Duties & Reason for Leaving

Employer

Job Title

Date of Employment

Duties & Reason for Leaving

Employer

Job Title

Date of Employment

Duties & Reason for Leaving

Camp Experience:

Camp

Camper or Staff?

Camp Location?

Dates Attended or Worked?

Camp

Camper or Staff?

Camp Location?

Dates Attended or Worked?

Please describe your understanding of autism spectrum disorders:

Describe your experience teaching the following skills:

 Communication & Language

Self Care Skills (eating, dressing, bathing, & toileting)

Social Skills

Describe your experience working with individuals with communication impairments

Describe your understanding or experience with behavior management techniques & indicate specific behaviors you have worked with

Conviction of illegal activity statement (check the correct box)

 I attest that I have never been convicted of any illegal activity other than minor traffic violations.
 I have been convicted of the following activities

If you answered yes to illegal activity, please provide description and dates

Permission to Conduct Criminal background Check statement:

Background checks are conducted after the interview process is complete. An acceptable background check is required for hire with the Autism Society of North Carolina Summer Camp Program. You must read the following information and then select one of the permission boxes.

In connection with my application for employment, I understand that consumer reports or investigative consumer reports which may contain public record information may be requested or made on me including consumer credit, criminal records, driving record, education, prior employer verification, workers compensation claims and others. These reports will include experience along with reasons for termination from various Federal, State, and local agencies which may contain my past activities.

I hereby authorize without reservation, any party or agency contacted by this employer to furnish the above information.

I understand I have the right to make a request of the Consumer Reporting Agency, upon proper identification and the payment of authorized fees, the information in its files on me at the time of my request. I further authorize ongoing procurement of the above-mentioned reports at any time during my employment/contract.

 I have read the above statement and give permission to the Autism Society of North Carolina to conduct a Criminal Background check.
 I have read the above statement and do not give permission to the Autism Society of North Carolina to conduct a Criminal Background check.

References:

The Autism Society of North Carolina requires two (2) written references for our files. Please download the reference form (.pdf format - you will need to use Adobe Acrobat Reader to open the file) and have two people who are familiar with your work complete and mail them to us as soon as possible. These may be from teachers, professors, or previous employers. It is your legal right to inspect these forms if you wish. Make sure to indicate on each reference form whether or not you waive your right to inspect the reference forms. Please list your references:

Reference # 1

Name & Title:

Email Address & Telephone

Address

City, State, Zip

Reference # 2

Name & Title:

Email Address & Telephone

Address

City, State, Zip

Please write a statement explaining why you want to work with people with autism.

If you are not contacted within 5 business days of submitting an application, please contact Sara Gage at sgage@autismsociety-nc.org or 919-542-1033.