Lincoln County School District #2 222 E. 4th Avenue P.O.

Box 219 Afton, WY 83110 (307) 885-3811 ♦ Fax (307) 885-9562 ♦ www.lcsd2.org

CERTIFIED EMPLOYEE APPLICATION

Last Name/ First/ Middle Present Address City/State/Zip Permanent Address City/State/Zip Indicate area of certification: Elementary Middle School

Date E-mail Address Home Phone Mobile Phone Date available for work High School

Indicate preference of teaching location: Star Valley

Cokeville

Any

ELEMENTARY- Indicate 1st and 2nd choice in the level for which you are interested. K-3 4-6 Subject Area (Elem. Ed., P.E. Art, Music, etc): MIDDLE SCHOOL Subject Area (Science, Math, P.E. Art, Music, etc): SECONDARY SCHOOLS 7-8 9-12

Any

7-12

Subject Area (Science, Math, P.E. Art, Music, etc): COACHING Please check the activities for which you are certified by the State of Wyoming and/or are willing to coach. Basketball Football Golf Volleyball Wrestling Track Speech Drama Other:

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Pursuant to definition of “highly qualified” by the No Child Left Behind Act, do you possess “highly qualified” status? _____ Yes _____ No. If “yes” please list by which state and attach evidence. ______________________________________________ If “no” , please state your plan for becoming highly qualified. __________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Pursuant to the provisions of W.S. 21-7-401, any employee who is to be hired by the school board on or after July 1, 1996, who may have access to minors, is required to submit to fingerprinting and to provide such other information as is necessary to acquire a national criminal history background check. Although a criminal history background check may have been done by the Wyoming Professional Teaching Standards Board, the school district may, at its option, conduct a separate criminal history background check. In addition, if you are not required to be certified by the Wyoming Professional Teaching Standards Board, or if you have not had a criminal history background check conducted by the Wyoming Professional Teaching Standards Board within the last 12 months, the school district may require you to submit to a criminal history background check. Have you provided the necessary information to the Professional Teaching Standards Board to allow it to conduct a criminal history background check? Yes No

Conviction of a crime is not an automatic bar to employment. The district will consider the nature of the offense, the date of the offense, and the relationship between the offense and the position for which you are applying. 1. Have you ever been convicted of an offense other than a minor traffic violation? (DUI and DWI convictions are not considered minor and must be reported.) 2. Have you ever been arrested for a felony? (Even if no contest or charges dropped or pled down.) 3. Have you ever been charged with a felony? (Even if no contest or charges dropped or pled down.) 4. Have you ever been convicted of a felony? (Even if no contest or charges dropped or pled down.) 5. Have you ever been arrested for a sex-related offense? (Even if no contest or charges dropped or pled down.) 6. Have you ever been charged with a sex-related offense? (Even if no contest or charges dropped or pled down.) 7. Have you ever been convicted of a sex-related offense? (Even if no contest or charges dropped or pled down.) 8. Have you ever been arrested for a drug-related offense? (Even if no contest or charges dropped or pled down.)

Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No

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9. Have you ever been charged of a drug-related offense? (Even if no contest or charges dropped or pled down.) 10. Have you ever been convicted of a drug-related offense? (Even if no contest or charges dropped or pled down.) 11. Have you ever been arrested for an act of violence, including domestic violence? 12. Have you ever been charged for an act of violence, including domestic violence? 13. Have you ever been convicted for an act of violence, including domestic violence? 14. Are you prevented from being lawfully employed in this country because of visa or immigration status? Proof of status will be required if employed. 15. Has your professional license ever been revoked?

Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No

16. Have you ever been discharged or separated from a position with a school district or been asked to resign a licensed arrangement? 17. Have you ever been the subject of an investigation by a school district or any other employer? 18. Have you ever had sanctions placed on your teaching certificate for any reason? 19. Have you ever been denied a teaching certificate anywhere? 20. Is disciplinary action currently pending anywhere against your certificate

Yes Yes Yes Yes Yes

If you answered yes to any of the above questions, and/or have any pending charges, as well as pleas of nolo contendre, please attach explanation on a separate sheet.

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1.

Please describe any professional or community activities, knowledge or skills you have which you think would be helpful in this position.

2.

Please list the instructional techniques you plan to use in your teaching.

I authorize Lincoln County School District #2 to obtain information about any criminal records I may have. I also authorize all governmental agencies to provide information to Lincoln County School District #2 about any criminal record I may have. I verify that all information on this employment application is true and complete. I understand that any misrepresentation, falsification, or omission on this application or other documents submitted to Lincoln County School District #2 will be sufficient cause for this application not to be considered by the School District or for dismissal if I have been employed. I authorize Lincoln County School District #2 to check my references, to obtain information from my prior employers and educational institutions, and to take other actions to investigate any information provided in my application employment, and to obtain information relevant to evaluating my qualifications and fitness for a teaching position. I authorize the release of any and all information or records maintained by the Wyoming Department of Family Services. I authorize my listed references, past employers and educational institutions, and anyone else who has information about my work history, education, qualifications, or fitness, to provide such information to Lincoln County School District #2. I release Lincoln County School District #2 and all persons providing information to the school district from any liability whatsoever for obtaining and providing that information.

A photocopy of this release shall be as effective as the original. Signature Date

Applicants for admission and employment, students, parents, persons with disabilities, employees, and all unions or professional organizations holding collective bargaining or professional agreements with Lincoln County School District #2 are hereby notified that this school district does not discriminate on the basis of race, sex, color, national origin, age, religion, or disability, in admission or access to, or treatment or employment in, its programs and activities. Any person having inquiries concerning the school’s compliance with the regulations

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implementing Title VI, Title IX, The Americans with Disabilities Act (ADA) or Section 504 is directed to contact the following individual who has been designated to coordinate efforts to comply with the regulations regarding nondiscrimination- Mark Taylor, PO Box 219, 222 E. 4th Avenue, Afton, WY 83110, (307) 885-3811. TTY- 1-800-877-9965

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