Self-Identification Data Record Form

Family & Children’s Center considers applications for all positions without regard to race, color, religion, sex, national origin, age, marital or
veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.

The purpose of this record is to comply with government record keeping reporting requirements to analyze applicant pools and compile
statistical reports.

This record will be kept in a confidential file, separate from your application or personnel file.

Please note: Completion of this information is voluntary.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY