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Name	First Last
Address	Street Address Address Line 2 City State Postal / Zip Code
SS Number
Date of Birth	MM / DD / YYYY
Phone Number	### - ### - ####
Cell Number	### - ### - ####
Emergency Contact Number	### - ### - ####
Email
What position are you applying for?	Teacher Site Director Assistant Site Director Bus Attendant Recruiter Driver
Do you have a criminal or protective service history?	Yes   No
If yes, please explain:
Do you have a Nation wide Finger Printed Police Clearance? If not, upon being contracted, you must obtain an official clearance.. (please note: clearance cannot expire before tutoring sessions end).	Yes   No
Do you have any health concerns or limitations that we should be aware of?	Yes   No
If yes, please explain:
How will you get to work? Do you have an alternative plan?
Please list special talents or other interest:
List current school of employment, principals name and school number (Principal will be called for reference) *If Applicable
Work Hours:
Are you a certified teacher?	Yes   No
Please upload your resume.
I understand, as stated by the Michigan Unemployment Insurance Agency, that this is a contractual agreement between myself and the Higher Ground Program, if I am contracted by the Higher Ground Program as a “Contractor/Tutor" I will be ineligible to collect unemployment, and is responsible for my own workers compensation plan. I futher understand that this contract, nor my position as a "Contractor/Tutor", with the Higher Ground Program is not based upon my ability to keep the number of allotted students.	Agree   Dissagree
Today's Date	MM / DD / YYYY
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