MomCo PDX

Kidsco worker application

We love MomCo Kids! Our goal is to create a safe, nurturing environment for all children. We will engage with stories, songs, and age-appropriate play. Thank you for your interest in investing in the lives of moms by helping care for their MomCo Kids. Your answers to the following questions will be kept in strict confidence.

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Birthdate

Gender

Marital Status

Have you used a name other than the above?

Yes

If so, please list and explain:

Because this position involves working with children we require a background check on all volunteers. If you do not wish to input your SSN at this time, you may leave it blank. We will call you to get the SSN over the phone.

Social Security Number

Besides Oregon, what other states have you lived in in the last 5 years (LIST ALL, if California, include county)?

References

Please list 3 personal references:

While it is not our intent to unnecessarily pry into your personal life, we are legally responsible to ask some questions concerning your background. Your responses will be held in the strictest of confidence and may be verified through an independent background check.

Have you ever been convicted of a crime?

Yes

If you have been convicted of a crime other than a minor traffic offense, please state the nature of the conviction, date, sentence received, sentence served (including dates and locations), probation or parole officers name and contact information, and any other facts or circumstances you can provide.

Have you ever been accused of or prosecuted for any abuse or sexual misconduct?

yes

If yes, please explain.

Signature

Please note: Acceptance of this application does not constitute a contract of employment and is not a commitment of any kind to this applicant.

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Kidsco worker application

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