Human Resource Office

200 Church Street

Landisville, PA 17538-1332
Phone (717) 898-5503 Fax (717) 898-5641
hroffice@hempfieldsd.org

Application for Support Staff

Position Applied For Date

(Applications will be kept active for one year)

Clerical Part-time
Instructional Aide Full-time
Noontime Aide Substitute
Child Nutrition
Health Room Nurse

Date Available to begin work: _________ Do you have a current Act 34, Act 151 & Act 114?

Last Name First Name Middle

Street Address City State Zip

Telephone Cell Phone

Educational Background

School Course or Major Years completed Diploma

Please list any special training, computer skills/programs, or experience in the area for which you are
applying.
Work Experience

Employer Location Ph. # Supervisor Position From/To

Are you currently employed?

Have you filed an application with Hempfield School District previously?

Have you ever been employed by Hempfield School District?

What is your minimum salary expectation? _________________

What is your current salary or most recent? ________________

Personal/Professional References Do not include relatives or past supervisors

Name Address Phone Occupation

Community Organizations, Special Interests

Act 34 of 1985 requires school districts to screen all potential employees for criminal history. The law
specifically requires criminal history records from the Pennsylvania State Police for Pennsylvania residents and
criminal history records from the F.B.I. for resident new to the state.

Act 151 of 1994, the Child Protective Services Law, requires that all public school employees hired as of July 1,
1996 must obtain a Pennsylvania Child Abuse History clearance through the Department of Public Welfare
Childline and Abuse Registry.

Act 114 of 2006 requires all public school employees hired as of April 1, 2007 to provide a Federal Criminal
History Record. Procedures to obtain this can be found at www.pa.cogentid.com.

It is the responsibility of the applicant to complete the forms, receive the reports, and have them recorded with
Hempfield School District.

The successful candidate’s employment will become effective with Board of Education confirmation.

The Hempfield School District is an equal opportunity education institution and will not discriminate
against any employee or applicant on the basis of race, color, age, creed, religion, gender, sexual
orientation, ancestry, national origin/ethnicity or handicap/disability in its activities, programs or
employment practices as required by Title VI, Title IX, Section 504 of the Vocational Rehabilitation Act
of 1973, and the Americans with Disabilities Act. For information regarding Civil Rights or Grievance
Procedure within the district, contact Christopher S. Adams, Assistant Superintendent, at (717)898-5561.

My signature below authorizes Hempfield School District to check with my present and/or past
employers and references. I also authorize investigation of all statements contained in this application for
employment as necessary in making an employment decision.

Signature

Date