Form 4729t - Staff Register - Division Of Children And Family Services
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1Assigned Site:______________________
HS:_______ EHS:_______ SP:_______
Division of Children and Family Services
Staff Register
RIVERSIDE COUNT Y
RIVERSIDE COUNT Y
OFFICE OF EDUCATION
OFFICE OF EDUCATION
(Please print or type)
Employee’s Name: ________________________________________________________________________
(Last)
(First)
(MI)
Home Address: ___________________________________________________________________________
(Street)
(City)
(Zip)
Home Phone:____________________ Date of Birth:_____________ Soc. Sec. #:_____________________
Primary Language:____________________________ Other Language(s): ____________________________
Ethnicity (optional):___________________________ Race (optional): _______________________________
Date of Hire:_________________________ Current Postion Title: __________________________________
Effective date of current position:___________________ Full time_____________ Part time _____________
Are you a current Head Start parent?
Yes
No
Former parent?
Yes
No
Education History: (Check each box)
High School Diploma:
Yes
No
G.E.D.:
Yes
No
Degrees: (Answer all boxes)
1. AA:
Yes
No
The degree is in:
ECE
FCP
Related Field
2. BA/BS:
Yes
No
The degree is in:
ECE
FCP
Related Field
3. Masters:
Yes
No
The degree is in:
ECE
FCP
Related Field
4. Doctorate:
Yes
No
The degree is in:
ECE
FCP
Related Field
5. If no degree, what is the number of ECE units completed? ___________________________________
6. If no degree, what is the number of Supervisory units completed? _____________________________
7. If you have an AA, are you currently working on a Bachelor’s?
Yes
No
8. Currently enrolled in:
ECE or related program
Yes
No
FCP program
Yes
No
Credentials Held: (Check all that apply)
CD Assistant
CD Associate Teacher
CD Teacher
CD Master Teacher
Site Supervisor
Program Director
Other (Specify)__________________________________
Health: (Answer all boxes)
Date of last T.B.:_________________ Result:____________________ Date of last physical:______________
CPR Certificate:
Yes
No Exp. Date:____________
First Aid Certificate
Yes
No Exp. Date:____________
FORM NO. 4729T
(Revised 10/09)
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