South Henry School Corporation

Home of the Titans

             (Printable version)



6972 So. St. Rd. 103

Straughn, IN  47387







1. Name in full (Ms.)


                          (Mr.) ___________________________________ 


2.  Present address_____________________________________ Phone (    ) _____________


                             _____________________________________ Zip Code______________


3.  Permanent address __________________________________ Phone (    ) ____________


                                    __________________________________ Zip Code______________


4.  For what position (grade or subjects) do you wish to apply?_________________________




5.  Organizations to which you belong? _____________________________________________                              

6.  Do you hold an Indiana license? _____ Give title & grades or subjects it covers?


    ______________________________Expires_____________, 20______


7. When could you begin work? __________ Are you under contract for next year? ___________



8. Underscore any of the following which you are able to direct successfully: Debates, School

    Plays, Oratorical Contests, Orchestra, Band Clubs, Football, Basketball, Baseball, Track,

    Tennis, Playground Activities, Wrestling, or Golf. (Add any others)



9. Please give in detail your Educational and Professional Training





School or Institution (Name & Location)              Degree or Diploma        Dates Attended


High School________________________________________________________________________




Graduate Work_________________________________________________________________




10. References:  List five references, including superintendents and principals under whom you

have taught.  If references are listed in college credentials, it is not necessary to list them.


 Name                            Address                      Telephone                     Official Position














11. Give complete information regarding your TEACHING EXPERIENCE



    Name of School                        Location           Grade or Subject     Date    Critic Teacher








Name of School                        Location           Grade of Subject     Date     No. of Years





13.   Please give a brief reason for wanting to be considered for a position with the SOUTH





















Request for Background Information


Employment in the South Henry School Corporation involves working with our student population.  We ask that you complete the questions below to help us evaluate your suitability to work with these students.  All applicants for employment are expected to provide us with this information.

Any misrepresentation or omission of fact may be grounds for disqualification from further consideration, or for termination from employment regardless of when the misrepresentation or omission is discovered.

The conviction of a crime, or any affirmative answer provided by you is not an automatic bar to employment.  Employment evaluators will consider the nature of any conviction or alleged conduct underlying the affirmative response, the date of the alleged conduct in question, your intervening conduct and the relationship between the offense and the position for which you are applying.


1.  If you are now working, is your conduct as an employee, or the quality of your work, the focus of any investigation by your current employer?    Yes______    No_______


2.  Have you ever resigned from a job after being disciplined by your employer, of after being offered the opportunity to resign rather than be terminated?   Yes______ No ______


3.  Have you ever been investigated for, charged with, or plead guilty or “no contest” to any crime involving the sexual abuse of any person or indecency with a minor?  Yes_____   No______


4.  Have you ever been charged with a crime other than a minor traffic offense, where the court has deferred further proceedings without entering a finding of guilt and placed you on probation, public service, or education program?   Yes_____   No________


     (If yes is answered to any of the above questions, explain the circumstances on a separate

      sheet and attach it to this application.)


Authorization and Release


     I authorize the South Henry School Corporation to check my employment history, including without limitation, reference checks, and to seek the release of investigator information, including an “expanded criminal history” possessed by any private or public employer or any local, state, or federal agency concerning matters described herein.  I will cooperate to the extent necessary to obtain the release of this information.

     I expressly waive in connection with any request for, or provision of such information, any claims or causes of action including without limitation, defamation, infliction of emotional distress, invasion of privacy, or interference with contractual relations that I might otherwise have against the school corporation, its officials, employees, trustees or agents, or against any provider of such information.

     I have read this authorization and release of all claims and I agree to the terms set forth.



_____________________________                                                         Date____________

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