Substitute Teachers

TWO RIVERS PUBLIC SCHOOL DISTRICT

Schools:
Two Rivers High School
L.B. Clarke Middle School
J. Koenig Elementary
J.F. Magee Elementary

APPLICATION – INSTRUCTIONAL STAFF

The Two Rivers Public School District is an equal opportunity employer.

PERSONAL INFORMATION

DATE _________________________ SOCIAL SECURITY NUMBER ___________________________

NAME ______________________________________________________________________________________

LAST FIRST MIDDLE

PRESENT ADDRESS __________________________________________________________________________

STREET CITY STATE

PERMANENT ADDRESS ______________________________________________________________________

STREET CITY STATE

TELEPHONE – Home ________________________ TELEPHONE – Work ___________________________

HOME EMAIL _________________________________________________

ARE YOU HISPANIC OR LATINO (Select one) YES NO

ARE YOU? (If you selected No above, you MUST select at least one below)

1 – American Indian or Alaskan Native

2 – Asian

3 – Black or African American

4 – Native Hawaiian or Other Pacific Islander

5 – White

All offers of employment are contingent on the production of documents which verify eligibility to work in this country.

EMPLOYMENT DESIRED

Positions for which you have applied in order of preference:

1. _________________________________  Elementary  Administrative

2. _________________________________  Middle School  Teacher

3. _________________________________  High School  Aide

 Substitute – levels

______ K-5 _____ 6-8 _____ 9-12

SUBJECTS (Please list) ____________________________________________

_____________________________________________

_____________________________________________

EDUCATIONAL HISTORY

High School __________________________ Location _____________________ Did you graduate? ________

COLLEGE OR UNIVERSITY TRAINING

Degree Earned

School Location Dates Attended Major Minor and Date

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________
COLLEGE OR UNIVERSITY TRAINING – Cont’d.

Degree Earned

School Location Dates Attended Major Minor and Date

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Undergraduate grade point average___________________ Graduate grade point average_____________

Credits beyond Bachelor’s Degree____________________ Credits beyond Master’s Degree__________

Scholastic Honors______________________________________________________________________

Extra Curricular Activities_______________________________________________________________

TEACHING EXPERIENCE

Student Teaching

Dates Location Grade/Subject Cooperating Teacher Telephone #

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Substitute Teaching

Dates Location Supervisor Number of Years

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Regular Teaching – Under Contract (full- and/or part-time)
Number of
Dates Location Assignment Supervisor Reason for Leaving Years

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

EXTRA-CURRICULAR ACTIVITIES

List activities that you are qualified to coach or direct.

1.____________________________________________ 2.___________________________________

3.____________________________________________ 4.___________________________________

LICENSE/CONTRACT/BACKGROUND INFORMATION

Current Licenses Held (Subject/Grade) DPI License Code Issued by Which State? Exp. Date

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Are you now under contract for next school year? ______ Yes _______ No

Have you ever been dismissed or had your contract not renewed or resigned from employment based in whole or in part on evidence that you engaged in immoral conduct? _______ Yes _______ No

If yes, please provide an explanation below:

_____________________________________________________________________________________

_____________________________________________________________________________________

Have you ever voluntarily surrendered your teaching license, or have you ever had action taken by an agency to have your teaching license revoked?

_______ Yes _______ No

If yes, please provide an explanation below:

_____________________________________________________________________________________

_____________________________________________________________________________________

Have you ever been convicted of a felony or misdemeanor? _______ Yes _______ No

If yes, please provide an explanation below:

_____________________________________________________________________________________

_____________________________________________________________________________________
(A conviction will not be an automatic bar to employment and will be considered only as it relates to the job in question.)

Have you ever paid a civil forfeiture or fine for a nontraffic-related offense (including municipal ordinance violations?)

_________ Yes _______ No

If yes, please provide an explanation below:

_____________________________________________________________________________________

_____________________________________________________________________________________
(Payment of a civil forfeiture or fine will not be an automatic bar to employment and will be considered only as it relates to the

job in question.)

Do you have any charge(s) pending against you? _______ Yes _______ No

If yes, please provide an explanation below:

_____________________________________________________________________________________

_____________________________________________________________________________________
(A pending charge or arrest is not an automatic bar to employment and will be considered only as it relates to the job in question..)

REFERENCES

Name School Address Telephone

Last Principal _________________________________________________________________________

Last Superintendent ____________________________________________________________________

Other References ______________________________________________________________________

_____________________________________________________________________________________

Credentials are on file at: ________________________________________________________________

(Applicants should request that credentials be forwarded to the District. Applicants must submit a

complete set of credentials including transcripts showing all coursework taken.)

PERSONAL STATEMENT

You have applied to our school district which is described as exemplary and focused on learning using a variety of teaching styles and techniques. Tell how you would function as a team member in a setting such as this which is known for its innovation and flexibility in implementing change.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

AUTHORIZATION

I authorize investigation of all statements contained in this application or made by me during my interview. I understanding that misrepresentation or omission of facts called for is cause for dismissal. I agree that the District shall not be held liable if I am denied employment or terminated following employment if it is verified that I submitted false statements and/or omitted substantive information.

Dated:___________________________ APPLICANT:_______________________________________________

I voluntarily grant the Two Rivers School District the right to investigate the statements I have made in this application, as well as other job-related information and activities. This investigation may include a consumer report or report from a retail credit bureau. I also authorize any former employer, person, firm, corporation, or government agency to disclose to the Two Rivers School District any information they may have regarding me. I release the Two Rivers School District, a well as any providers of information, from any liability, and for any damage which may result from the furnishing of this information.

Dated:___________________________ APPLICANT:_______________________________________________

FOR OFFICE USE ONLY
Interviewd by: Date:
Salary Classification: Assignment:
Contract Issued: Credits Approved:
Board Approval:

DISCLOSURE STATEMENT & CONSENT TO CONDUCT CRIMINAL CHECK

The tremendous responsibility the Two Rivers Public School District has to its school children and community necessitates the following information from all applicants regarding convictions.* A record of conviction does not prohibit employment; however, failure to complete this form accurately and completely may mean disqualification from consideration for employment or may be cause for dismissal if employed. Applicants must report any convictions that occur subsequent to the time they initially completed this form. Please provide all the information requested within three work days to the District Administrator, Two Rivers Public School District, 4521 Lincoln

Avenue, Two Rivers, WI 54241.

Name_______________________________________________________________________

Current Address_______________________________________________________________

Other Names Used_______________________________ Dates of Usage________________

Social Security Number___________________________ Date of Birth__________________

Have you ever been convicted* of or do you presently have pending any violations of law other than minor traffic violations?

(In accordance with state law, convictions or pending charges will not be used or considered unless they are substantially related to circumstances of the particular job.)  No  Yes If yes, please fill in the information below and attach a letter of explanation. If you have more than two convictions or pending charges, list them on a separate sheet.

CONVICTION INFORMATION

Conviction charge # 1 Conviction charge #2 a. Date of Conviction: b. Court of Conviction: c. City: d. State: e. Amount of Fine: f. Length of Jail Term: g. Remarks: h. Length and Terms of Probation:

*Conviction means the final judgment of a verdict or a finding of guilty, a plea of guilty, or a plea of nolo contendere, in any municipal, state,

or federal court of competent jurisdiction in a misdemeanor, civil, or criminal case, regardless of whether an appeal is pending or could be

taken. Conviction does not include a final judgment which has been expunged by pardon, reversed, set aside, or otherwise rendered invalid.

I authorize the Two Rivers School District to contact the Wisconsin Department of Justice (Criminal Information

Bureau) as well as any other local or state law enforcement office, to investigate all statements contained herein and understand that any document relevant to this information may be reviewed by the agents of the Two Rivers Public

School District. I also authorize the District to obtain any and all information resulting from background checks or investigations conducted by the Department of Public Instruction. I understand that my employment is not finalized until the background investigation has been completed. This consent shall be interpreted liberally in favor of the District’s access to information.

I certify that the information provided above is true and correct without omissions of any kind. I agree that the

District shall not be held liable in any respect if my employment is denied or terminated because of false statements, answers provided, or omissions made by me in this application. In consideration of the school district’s review of this application, I hereby release the District as well as all providers of information from any liability and for any damage which may result from the furnishing and receiving of this information.

____________________________________________________________________________________

Signature Date

The Two Rivers Public School District does not discriminate on the basis of sex, race, color, religion, national origin, ancestry, creed, pregnancy, marital status or parental status, sexual orientation, or physical, mental, emotional, or learning disability or handicap in its education program or activities.

Job Type: Part-time

Pay: $150.00 - $200.00 per day

Expected hours: 8 – 40 per week

Grade levels:

• Elementary school
• High school
• Middle school

Schedule:

• 8 hour shift
• Day shift

School type:

• Public school

Work Location: Multiple locations