--Select Position for Which You Are Applying-- Instructor Intern Medical Director Head Cook Assistant Cook

NAME:
(required)

Date of Birth: (required)

E - MAIL ADDRESS: (required)

ADDRESS:

CITY / TOWN:

STATE:

ZIP CODE:

COUNTRY:

PHONE #'s:

HOME: (required)

CELL:

WORK:

FAX:

EMERGENCY INFORMATION

NAME OF EMERGENCY CONTACT:

LAST:

FIRST:

FULL ADDRESS OF EMERGENCY CONTACT:

PHONE #'s OF EMERGENCY CONTACT:

HOME:

CELL:

WORK:

RELATIONSHIP WITH EMERGENCY CONTACT:

HEALTH INFORMATION

MEDICAL INSURANCE COMPANY:

MEDICAL INSURANCE CO. PHONE #:

INSURANCE

ID#:

GROUP #:

PRIMARY PHYSICIAN:

PHYSICIAN'S PHONE #:

ANY DIETARY OR ALLERGY CONCERNS:

ANY PERTINENT MEDICAL CONDITIONS, INFORMATION
AND MEDICATIONS WE NEED TO BE AWARE OF:
(In other words, if something happens to you,
what would you want us to know about your medical history.)

DATE OF LAST TETNUS SHOT?:

Have you ever been convicted of a felony?

Yes

No

If Yes, please describe:

PERSONAL HISTORY

Highest Level of formal Education:

High School

College/University

Name of School, Degree and Main Focus:

Work Experience:
List ANY relevant work from at least two previous jobs
you have held and the reasons for leaving:

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ESSAY QUESTIONS
Textfields will expand accordingly.

Please list ALL your Tracker and COTEF courses, and the years you have taken them:

Please list ALL the Tracker and COTEF courses you have VOLUNTEERED for,
and the years you have taken them:

What did you gain from your volunteering experiences?

Why do you want to be an INSTRUCTOR / INTERN?

Why are you the best choice for the position?

Describe your personal understanding of what the INSTRUCTOR / INTERN Program
really is and what role the caretaker plays:

Describe a situation in which you have been self-motivated:

Describe a situation in which your work ethic was evident:

Describe any teaching experiences you have had and what you learned from them:

What are your personal challenges when working with people:

Describe any leadership roles you have held:

What were your challenges and lessons?

What strengths will you bring to your INSTRUCTOR / INTERN position?

What weaknesses will you bring?

What is your attraction to the COTEF?

Why do you want to be an INSTRUCTOR / INTERN at the COTEF specifically?
Why not go elsewhere?

Describe a community living experience and what you learned from it:

What are your goals and expectations for
yourself during your INSTRUCTOR / INTERN time?

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If not a United States citizen or American -
Please give any other important country information necessary to contact you.

If not a US citizen or American, what is your Visa #?

Expiration Date?

Do you have any Children?
If so, how many?

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Will you be bringing a vehicle?

Vehicle Make:

Model:

Color:

Registration Number:

License Plate - State & #:

Driver's License - State & #:

Expire Date:

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Please allow 2 weeks to receive confirmation and follow up information.

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Click SUBMIT only ONCE please.