MyCenter Staff Record

3547 Georgia Avenue, Silver Spring, Maryland 20901
You MUST Save Progress or Submit before leaving this form or ALL entries will be lost.

Contact information

Please enter your full name (example: use Joseph not Joe)
Gender *
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Enter telephone numbers as 10 digits with no other characters
Cell phone carrier: Select your cell phone carrier from the list to enable us to inform you of schedule changes and other events via text message. Messages will be sent to the first cell phone listed.

Office use only - only administrative staff will see this section

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Employment status
Received
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Required periodic training
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Education

Graduated with
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45 hour course 🛈
90 hour course 🛈
Other training 🛈
Teaching certificate or certification *
Montessori Credentials *
Additional early childhood training
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Early childhood related work experience

List most recent employer first
Experience means paid or unpaid employment as a teacher, assistant teacher, aide, or student intern in a public or non-public school serving children 12 years or under, in a licensed child care center or hours worked as the license holder of a licensed family day care home. Do not list any unrelated work experience.
Enter telephone numbers as 10 digits with no other characters
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Emergency contacts

Enter telephone numbers as 10 digits with no other characters

Affirmations and agreements

Immunization statement *
I understand that *
Policy statement *
Rules and regulations *
Image authorization: Check yes to authorize our use of photographs and videos of you on our website, social media page, and in our promotional materials.
Image authorization *

Government forms

All employees are required to complete the following forms and return them to the Center office. Click on the form name to download.
 
I-9 Employment Eligibility Verification
 
W-4 Employee's Withholding Allowance Certificate
 
State Withholding Certificate
 
 

Direct deposit

I authorize my employer to deposit my wages or salary into the bank account specified below.  My signature below indicates that I am agreeing that I am either the account holder or have the authority of the account holder to authorize my employer to make direct deposits into the account.
Account type

Non-disclosure policy

Members of our staff, including employees and volunteers, will of necessity have access to this facility’s confidential information during the course of their work for this facility. Confidential information comprises any information obtained as a result of work for this facility orally or by any other communication medium including, but not limited to, documents, electronic files, web pages, or email messages. Confidential information includes, but is not limited to, names of children attending this facility at any time, names of their family members (including care givers, emergency contacts, individuals authorized to pick up child), family member contact information, information provided in registration forms, and information provided in communications with family members. Confidential information also includes information about the facility, employees, volunteers, and other members of the facility community.

Confidential information does not include any information that:
● becomes publicly known, as by a public use or by publication, or otherwise ceases to be confidential, except through a breach of this policy by the staff member;
● is designated by the facility as not confidential

Staff are authorized to use and disclose confidential information exclusively for performance of their  duties for the facility. Staff members shall not use or disclose confidential information for any other purpose. Any other intentional use or disclosure of confidential information shall constitute a breach of the staff member's work agreement and shall be sufficient cause for immediate termination of staff member's work for the facility and legal action against the staff member.

Upon termination of work for the facility, former staff members shall not:
● retain any electronic or physical copies of confidential information
● disclose any confidential information in perpetuity
● initiate communication with children attending this facility or their family members at any time. Former staff members may engage in communication with such individuals if such individuals initiate the communication.

Staff signature

I understand and agree to comply with the non-disclosure policy.
I certify that the information I have provided is complete and accurate to the best of my knowledge.
 
I certify that my electronic signature entered below is legally binding.
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