Your Name:


Address:  


City:    State:    Zip Code:  


Email Address:     Phone Number:


Name of Church:    Phone Number of Church / Pastor:  


Name of Pastor:


How long have you attended this church:  


Frequency of church attendance: Occasionally   Regularly   Never


Are you a Christian?  yes   no


Have you ever been charged or convicted of a felony?  yes     no


How many hours per week are you desiring?  


Jobs interested in performing (check all applicable):  

 Custodial
 Cook
 Infants
 2 years of age (K2)
 3 years of age (K3)
 4 years of age (K4)
**If there are jobs that you do not particularly care for, please do not select

Other (please specify):  

Childcare Experience:   None     1-2 years   3+ years
Do you have your North Carolina Early Childhood Credential?  yes  no
Do you use social media (i.e. Facebook, Linked In)?  yes   no
If you use social media, either provide us with the URL or the name(s) under which your social media page(s) can be found:

Education Level:  
 Not a High School Graduate
 High School Diploma
 Some College
 Associates Degree
 Bachelors Degree
 Masters Degree

Previous Employer:  
Give a brief explanation of your interest in obtaining a position in Christian childcare:
Expected rate of pay: