Early Intervention Application

Early Intervention Application
Date*

MonthDayYear
DateHourMinutesAM/PM Option
Name*

First NameMiddle NameLast Name
Preferred Name
Phone Number*

Area CodePhone Number
Email*
Social Security Number*
123-45-6789
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driver's License*
Date available to start*

MonthDayYear
Date
Employment Type*
Have you ever been convicted of a crime?*
If yes, please explain:
Have you ever been employed with Easterseals?*
If yes, please indicate when, where, and what position that you held with Easterseals.
Are you authorized to work in the United States?*
Education:

This position requires a Bachelor's Degree in one of the following areas; Early Childhood Education, Child Development and Family Studies, Special Education, Social Work, Sociology, Psychology, or another related field from an accredited college or university.
Employment History:
Most Recent position*
Number of years experience working with children?
Explain your experience working with children*
Are you CPR certified?*
Upload CPR certification here.

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Upload your Resume*

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Early Intervention Division Applicant Consent Release
Caution to the applicant! Please read carefully!
1.   I understand that prior to an offer of employment with Easterseals South Carolina, that Easterseals South Carolina will order a South Carolina Department of Social Services(SCDSS) Central Registry of Child Abuse and Neglect Database Check, Federal Criminal Record Check (via the DHEC Direct Caregiver Application for Electronic Scan Bureau of Health Facilities Regulation electronic, fingerprint scan), and a South Carolina Law Enforcement Division (SLED) Criminal Records background checks. If any of the reports reveal any negative history, employment will not be offered. Please do not continue this Employment Application process if any of the checks listed in this section will reveal a negative history.

2.       I understand that prior to an offer of employment with Easterseals South Carolina, that Easterseals South Carolina will complete the Centers for Medicare and Medicaid Services (CMS) List of Excluded Individuals/Entities (LEIE) Check on me. If the CMS LEIE reveals any negative history, employment will not be offered. Please do not continue this Employment Application process if your CMS LEIE report will reveal a negative history.

3.       I understand that prior to an offer of employment with Easterseals South Carolina, that Easterseals South Carolina will order a South Carolina Department of Motor Vehicle (SCDMV) Request for Driver Information Report, as required by Easterseals South Carolina’s liability insurance carrier. If my SCDMV Request for Driver Information Report indicates more than two (2) moving violations or at-fault accidents within the three (3) years immediately preceding, license suspension, or driving without insurance then employment will not be offered.

4.   After the interview, if Eastersesals South Carolina decides to move forward with employment, I understand that I will be required to provide the following:

a.    An official, sealed college transcript from all colleges or universities indicated on my application and/or resume. (Note: Photocopies of transcripts are not accepted. Transcripts must be official and sealed as provided and authenticated by the school providing the transcript). No offers of employment will be extended without official transcripts received by Easterseals South Carolina.

b.   A sealed Letter of Reference from a former employer or a completed, sealed Service Letter from a former employer. An offer of employment will not be extended without receipt of one of the letters stated above.

c.    A copy of my automobile insurance card and the automobile insurance declaration page from my automobile insurance policy. An offer of employment will not be extended without receipt of copies of the documents stated above.

5.   I understand that if I am employed by Easterseals South Carolina, that all Federal and State Background Checks listed in #1, #2, and #3 will be checked throughout employment with Easterseals South Carolina. If at any time, my Federal or State Background Checks reveal a negative history, employment with Easterseals South Carolina may be terminated.
Applicant's Signature*

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I understand that the items mentioned above are absolute requirements, and Easterseals South Carolina’s use of and reliance on these items is not negotiable. If you anticipate that one or more of these items will present a problem, then please address your concerns with the Easterseals South Carolina’s Director of Human Resources prior to submitting your completed application.

By my signature, I consent to the release of information to authorized officers, agents, and employees of the State of South Carolina, which may include, but not be limited to information concerning my past and present work; including my official personnel files; attendance records, evaluations, education records including transcripts, military service, law enforcement records; and any personnel record deemed necessary. In addition, I consent to authorize appropriate officers, agents, and employees of the State to make inquiries of third parties. I further release the organization, educational entity, present and former employers, law enforcement organizations, and all third parties from any and all claim of whatever nature that I may have as a result of any inquiry or response given to such inquiries made in connection with my application for employment.

By my signature, I affirm, agree, and understand that all information on this form is true and accurate. Any misrepresentation, falsification, or material omission of information or data on the application may result in exclusion from further consideration or if hired, termination of employment. If I have requested herein that my present employer not be contacted, an offer of employment may be conditioned upon acceptable information and verification from such employer prior to beginning work.
Applicant's Signature*

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Early Intervention Application

Education:

Employment History:

Early Intervention Division Applicant Consent Release