PIONEER

VALLEY

BERNARDSTON

REGIONAL LEYDEN

SCHOOL

NORTHFIELD

DISTRICT

WARWICK

SUBSTITUTE APPLICATION Name: ____________________________________________________ Date: ____________ Address: ____________________________________________________________________ Tel. #: ______________________________ Email: _________________________________ High School: _______________________________________ Yr. of Grad.: ____________ College: ____________________________________________ Major: __________________ Yr. of Grad.: ___________ Certification #: __________________ Area: ______________ Experience: 1. List those schools in which you have taught on a permanent basis and the dates (chronologically): ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 2. List those schools in which you have substitute taught: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 3. List other experience which would assist you in substitute teaching: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Availability: 1. Circle those days on which you would normally be available: M T W Th F 2. Indicate any restrictions to your availability: ___________________________________________________________________________ ___________________________________________________________________________ 3. Schools you wish to sub at: ___BES ___NES ___ PRES ___WCS ___ PVRS 4. I would like to be considered to sub: ___ Teacher ___ Paraprofessional ___ Custodian ____ day ____ evening ___ Secretary Other: ________________

Grade level: Check those areas in which you would feel qualified to carry out the regular teacher’s plans. Primary Level (K-3) Elementary (4-6) Middle School Level (7-8) High School Level (9-12) Art Computer Technology Foreign Language Gym Music List any subject(s) you would prefer not to cover: _______________________ ________________________________________________________________________ References: Name

Address

Position

Tel. #

__________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Applicant’s Signature: ___________________________________ Please return to: The Office of the Superintendent Pioneer Valley Regional School District 168 Main Street, Suite 1 Northfield, MA 01360 (413) 498-2911 Hiring of the applicant is subject to a National Background and CORI check, satisfactory to the employer, and is a condition of hiring or continuation of employment prior to the receipt of the above referenced criminal checks. The Pioneer Valley Regional School District does not discriminate on the basis of race, color, religion, national origin, age, sex, gender identity, sexual orientation, housing status, or disability in admission to, access to, employment in, or treatment in its programs and activities.