Peter Pan Early Learning Centers

Quick Links▼

Peter Pan of Westmont

Peter Pan
Early Learning Centers

CFS 508-1

Rev. 11/2002

	State of Illinois	HIGHLIGHT THIS PAGE & "PRINT"
	Department of Children and Family Services	________________________
		Date Submitted

INFORMATION ON PERSON EMPLOYED IN A CHILD CARE FACILITY

I.	Employing Facility: Peter Pan Early Learning Centers (check one)
	□ Peter Pan Early Learning Center ~ 24 W 760 75th Street, Naperville, IL 60565
	□ Peter Pan North Preschool ~ 1190 Olesen Drive, Naperville, IL 60540
	□ Little Shepherd ~ 1020 West Jefferson, Naperville, IL 60540
	□ Peter Pan Early Learning Center - 6551 South Cass Avenue, Westmont, IL 60559
II.	Person Employed: ______________________________________________ Date: _________________________
	Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Phone: _______________________________
	Home Address: ______________________________________ ______________________ __________________
	(Street and Number) (City) (Zip)

III.	Employment Date Employed: ________________________________
	Position for which employed (check appropriate box)

	□ Executive, Superintendent, or Director	□ Licensed Practical Nurse (day care center only)
	□ Child Care Supervisor (child care institution)	□ Master Teacher
	□ Child Care Worker (child care institution)	□ Early Childhood Teacher (day care center)
	□ Child Care Staff (group home)	□ School-Age Worker (day care center)
	□ Child Welfare Supervisor (child welfare agency)	□ Early Childhood Assistant (day care center)
	□ Child Welfare/Licensing Worker (child welfare agency)	□ School-Age Assistant (day care center)
	□ Registered Nurse	□ Substitute
	□ Teacher (residential facility)	□ Cook
	□ Housekeeping	□ Clerical
		□ Other: ___________________________________

IV.	Previous Employment (Last 10 Years of Employment)
	From	To	Name and Address of Employer	Type of Work and Title
1.
2.
3.
4.

V.	Other Direct, Unpaid Experience with Children (such as Scout Work, Sunday School, School Teacher)
	_________________________________________________________________
	_________________________________________________________________
	_________________________________________________________________
	_________________________________________________________________

Report of Reference on File (At least 3 character and/or business, from persons not related to the employee)
Name of Reference	Address	Relationship
1.
2.
3.

VI.	Educational Background (Circle the one item indicating highest grade completed)

	Elementary Grade: 0 1 2 3 4 5 6 7 8
	High School: 1 2 3 4
	GED: □ Yes □ No

	Years of College (Undergraduate): 1 2 3 4
	Years of Graduate Work: 1 2 3 4

	College Degree: __________________________________ Graduate Degree: _______________________________
	Name of School, College, or University last attended: ___________________________________________________
	Other Special Training or Professional License (Specify): ________________________________________________
	Professional License Number: ______________________________________________
	Evidence of Educational Achievement on File: □ Yes □ No (If "No", please explain)
	_________________________________________________________________________
	_________________________________________________________________________
	_________________________________________________________________________

VII.	Physical Examination
	Last Examination (Date): _______________________________
	Name and Address of Examining Physician: ___________________________________________________________
	Health Clearance Report on File? □ Yes □ No

VIII.	Certification of Employment
	I, the employer, or authorized official of the employing facility, do hereby certify that the above-named person is employed in the position indicated and that, to the best of my knowledge is qualified for the position indicated, and employment is in accordance with minimum standards prescribed by the Department of Children and Family Services.
	Signed:_____________________________________________________

	Executive Director/Director:_____________________________________________________