2021-22 South Adams Schools Substitute Teaching Application
[Pages:2]South Adams Schools Substitute Teaching Application
(8/8/97)
2021-22
Today's Date:_____________________
Name: ________________________________________
Telephone #: _____________________
Address: ______________________________________
Email Address:_______________________________
High School Attended: ___________________________
College Attended: _______________________________
Degrees Earned: __________________
MAJOR: ______________________________________
MINOR: ________________________
Emergency Contact Information ? Name:_________________________________ Telephone # _________________
Do you have a high school diploma?
YES NO State: __________ Date: ___________
Do you hold a VALID Indiana Teaching License?
YES NO Number: ________________________ Expiration Date:__________________
Do you hold a VALID South Adams Substitute License?
YES NO Number: ________________________ Expiration Date: _________________
Do you hold a VALID Substitute License from another school? YES NO Which District: __________________ Expiration Date: _________________
Teaching/Substitute Teaching Experience (include school corporation, years, and subjects taught): _________________________________________________________________________________________________
_________________________________________________________________________________________________
Experience Working with Children (daycare, cadet teaching, camp work, life guarding, private or public work, church youth work, scouts, 4-H, etc.): _________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Indicate here the areas/grade levels in which you are interested in substituting: _________________________________________________________________________________________________
Indicate here the areas/grade levels in which you DO NOT want to substitute: _________________________________________________________________________________________________
Indicate any days you would NOT be available: _________________________________________________________________________________________________
How short of a time do you need from the time of notice to time to report for work? _________________________________________________________________________________________________
How early in the morning may we call you when needed for a 7:45 a.m. assignment? _________________________________________________________________________________________________
Note: Please complete reference information on back
South Adams Schools will not discriminate against any employee or student because of race, color, ethnic background, religion, sex, national origin, age, and/or disability. Questions regarding this statement should be directed to: Michelle Clouser-Penrod, 1075 Starfire Way, Berne, IN 46711, 260.589.3133.
References:
Personal references (please give two other than relatives):
Name:
Title or Position
Complete Address & Phone Number
1. ____________________
___________________ _____________________________________
2. ____________________
___________________ _____________________________________
Professional references (please give two individuals other than relatives who are knowledgeable concerning your experience working with children)
Name: 1. ____________________
Title or Position
Complete Address & Phone Number
___________________ _____________________________________
2. ____________________
___________________ _____________________________________
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