Name __________________________________

Street address: ______________________________________

City: _________________________, Postal Code ________________________

Telephone ______________________ email ______________________

Date ________________

Schooling ________________________________________________________________

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Relevant Courses/Training ____________________________________________________

________________________________________________________________________

_______________________________________________________________________

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Work Experience _____________________________________________________________

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Experience with children with autism ____________________________________________

________________________________________________________________________

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Are you hoping to work Part-time or Full-time (circle one).  If Part-Time,how many hours a week are you willing to work (minimum is 6 hr/wk) ___________

What time of day are you prepared to work? (please circle)

           Mon   Tues   Wed   Thurs   Fri   Sat   Sun

           am     am      am     am       am    am   am

           pm     pm      pm     pm       pm    pm   pm

           ev      ev       ev       ev        ev     ev    ev       ev = evening

Do your have use of a car? yes no

How far are you willing to travel?

Niagara yes no        Cambridge yes no        Guelph yes no       Mississauga yes no        Oakville yes no        Brantford yes no        Burlington yes no        St. Catharines yes no        Toronto yes no        Whitby yes no       

York Region yes no        London yes no        Windsor yes no        Pickering yes no        Brampton yes no

Barrie yes no        Other _________________________________       

What are your plans for the future? ____________________________________________

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Do you have any ailments that would affect your ability to work with children? yes no _____

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