Childcare Application – First Alliance Church

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Personal Information

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Daytime Phone

Are you a resident of Kentucky?*

Yes

If no, in which state are you a resident, and how long have you resided there?*

If yes, how long have you been a resident of Kentucky?*

Are you 18 years of age or older?*

Yes

If no, please give current age.*

Do you attend this church?*

Yes

Have you ever been convicted of or pled guilty or no contest to a crime other than a minor traffic violation, or are you now under charges for any criminal offense?*

A criminal conviction will not necessarily disqualify you from consideration.

Yes

If yes, please explain fully.*

Personal References

Please include complete addresses. Do not use relatives or former employers.

List four personal references who are well acquainted with you.*

Please use references that have seen you interact with children if possible.

Name

Email Address

Physical Address

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