Camp Rae Special Education

TeacherApplication
Social Security Number:
First Name

Middle Name
Last Name
(List any other name you may have used which would help us in checking your educational or experience record.)
Present Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Permanent Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Cell Phone

### 		-
### 		-
####
Home Phone

### 		-
### 		-
####
Can you submit proof of U.S. Citizenship?
 Yes 
 No 
If no, explain:
Emergency Contact Name

First
Last
Emergency Contact Address

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Emergency Contact Phone

### 		-
### 		-
####
Have you ever been convited of a felony or misdemeanor other than a minor traffic offense?
 Yes 
 No 
If yes, explain:
Are you currently under contract?
 Yes 
 No 
If Yes, where and for what period of time?
Do you possess professional certification as a teacher?
 Yes 
 No 
Teacher Certification #:
Date Issued:
Date of Expiration:
State in which certificate was issued:
Educational Level:
 BA 
 BS 
 BA+18 
 MA 
 MA+30  
 Doctorate 
Praxis Test Scores:
(Please include a copy of your scores if you do not have SC certification.)
Subjects and Grade Levels Certified To Teach:

EDUCATIONAL PREPARATION -High School and beyond

(List chronologically, beginning with most recent.)
Location of School/Dates Attended
School 1:
School 2:
School 3:

PROFESSIONAL EXPERIENCE

(List chronologically, beginning with most recent).
Location of School and Dates Employed
School 1:
School 2:
School 3:

OTHER WORK EXPERIENCE

List chronologically, beginning with most recent (full-time preferred)
Work Experience 1:
Work Experience 2:
Work Experience 3:
General:
References:
Personal Statement:
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