Employment Application Child Care Substitutes of Oregon Job Title: Substitute Provider, Child Care Substitutes of Oregon Department/Office: The Research Institute Recruitment number: S2294 Personal InformationFirst Name(Required) Last Name(Required) Preferred Pronouns Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) Are you over the age of 18?(Required) Yes No Are you eligible to work in the US?(Required) Yes No Will you now or in the future require visa sponsorship for employment at Western Oregon University?*(Required) Yes No Have you ever worked for Western Oregon University before?(Required) Yes No List department(s) and dates workedPlease list the name and department of any relatives who work for WOU. (This response is considered for placement purposes. WOU does not place relatives in positions which create supervisory/subordinate relationships):Central Background RegistryCentral Background RegistryAre you currently enrolled in the Central Background Registry? (Not required to apply) Yes No If yes, please provide your ORO Step if applicable. If yes, please provide your CBR# if applicable. Education InformationLevel of Education Completed (Check all that apply)(Required) GED Some High School High School Some College Community College (Associates) College (Bachelors) College (Post Bacc) Please describe any additional or relevant education or certifications: Job History InformationEmployer Job Title Address City State / Province / Region Supervisor (name) PhoneReason for Leaving Language, Experience, and TrainingsWhat is your primary language? Do you speak any additional language(s)? Yes No If so, what are your other language(s) If you speak more than your primary language, what is your proficiency? Reading Speaking Writing All of the above Not Applicable In which language would you like to receive communications?(Required)Please note: languages outside of English and Spanish may have a longer processing time. English Spanish Vietnamese Russian Mandarin ExperienceHave you ever worked in a child care facility? Yes No Have you ever owned or operated a child care facility? Yes No Trainings previously completed (non-expired) Infant CPR/First Aid Recognizing and Reporting Child Abuse and Neglect Food Handler Certification Safe Sleep for Infants Introduction to Childhood Health and Safety Prevention is Better than Treatment Foundations for Learning Reasonable Accommodation NoticeFederal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment. Western Oregon University is an AA/EOE/Veteran/Disability employer and is committed to fostering diversity in its student body, faculty, and staff.I hereby certify that the information provided in this application and/or supplemental materials is freely given, true, and complete. I understand that any false, fraudulent, or misleading statements, answers, or information may be sufficient grounds for immediate rejection of my application, denial of employment, disciplinary action or dismissal from service if hired. I authorize the Western Oregon University Human Resources Office (HR) to thoroughly investigate my work and educational history and verify data provided on this application or given during the selection process. Furthermore, I also authorize HR to conduct a criminal background investigation, check my driving record, or contact my present or past employers if necessary. I authorize all past employers mentioned herein to release employment information requested about me. I hereby release HR, as well as any other agency, school, or company contacted from any liability or damage which may result from obtaining the information requested. HR may give copies of my signed authorization to those contacted. Consent I agreeFull Name Date MM slash DD slash YYYY ALL INFORMATION BELOW IS OPTIONAL AND CONFIDENTIAL This page is used by the Human Resources Office only and is not seen by the hiring department.Position InformationJob Title Department/Office Recruitment Number Western Oregon University is committed to an affirmative action program that promotes the effective recruitment of women, members of racial/ethnic groups, individuals with disabilities, veterans, LGBTQ+ and community members, and others who demonstrate the ability to hlep us achieve our vision of a diverse and inclusive community. The information in this document will be kept confidential and used to fulfill reporting requirements. Completion of this form is voluntary; a decision not to disclose this information will not result in any adverse treatment of your employment application.Demographic InformationIn what city and state do you live? City State If in Oregon, what county? Affirmative Action InformationGender (check one) Male Female Trans or gender non-conforming Please indicate your ethnic identity by answering the following question:Are you Hispanic or Latino? Yes No Race (choose one or more) Asian or Pacific Islander: All persons having origins in any of the peoples of the Far East, Southern Asia, the Indian subcontinent, or the Pacific Islands. For example, this area includes, China, India, Japan, Korea, the Philippine Islands, and Samoa. Black (Not of Hispanic origin): All persons having origins in any of the Black racial groups of Africa. Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race. Native American or Alaskan Native: All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. White (Not of Hispanic origin): All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East. Veteran status information This employer is a government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires government contractors to take affirmative action to employ and advance in employment (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows: A disabled veteran is one of the following:A veteran of the U.S. military, ground, naval, or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; orA person who was discharged or released from active duty because of a service-connected disability A recently separated veteran means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.An active duty wartime or campaign badge veteran means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.An Armed Forces service medal veteran means a veteran who, while serving on active duty in the U.S. military, ground, naval, or air service, participated in a United States military operations for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.Please check one of the boxes below (Please provide a copy of your DD-14 to prove eligibility): I adentify as one or more of the classifications of protected veteran listed above I am not a protected veteran. Advertising informationWhere did you first learn about this position? Printed advertisement Web page Other Please Specify PhoneThis field is for validation purposes and should be left unchanged.
