Date: |
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Social Security Number: |
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* First
Name: |
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* Last
Name: |
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* Address: |
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* City: |
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* State: |
in United States |
* Zip
Code: |
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* Phone: |
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Work Phone: |
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Cell Phone: |
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Pager: |
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Fax Phone: |
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What phone number can you
be reached at
between 10:00 A.M. and 4:00 P.M? |
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E-Mail: |
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Languages Other
than English: |
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How did you
hear about our agency? |
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* WHAT TYPE OF
PROVIDER ARE YOU APPLYING TO BECOME?
Hold down the "ctrl" or "shift" keys
to select multiple choices
* WHAT KIND OF
EMPLOYMENT ARE YOU INTERESTED IN?
Hold down the "ctrl" or "shift" keys
to select multiple choices
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Are you able
to care for infants? |
YES
NO
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Experience?
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Are you able to care for
toddlers? |
YES
NO
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Experience?
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Are you able to care for
adolescents? |
YES
NO
|
Experience?
|
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Are you able to care for
elderly? |
YES
NO
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Experience?
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*When are you available
to begin employment? |
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Specify exact daily schedule
you are able to work in 24 hour format: |
Monday: |
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Tuesday: |
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Wednesday: |
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Thursday: |
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Friday: |
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Saturday: |
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Sunday: |
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Other |
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How many minutes are you
willing to travel to work? |
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* What
is your minimum starting salary? |
$
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* Do
you smoke cigarettes? |
YES
NO
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* Do
you have experience in running a household? |
YES
NO
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* What
tasks are you willing to perform?
(cleaning, cooking, shopping, gardening, etc.) |
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* Do
you object to pets? |
YES
NO
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* Do
you have any allergies to animals or other substances? |
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* Are
you certified in CPR? |
YES
NO
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* Minor
First Aid? |
YES
NO
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* Need
to recertify? |
YES
NO
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* Any
other Certifications? |
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* What
hobbies and sports do you enjoy and are currently doing? |
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Are you willing to
care for children who may have special disabilities behavioral or
learning problems? |
YES
NO
|
* Do
you feel you can run a household of 1, 2, 3, 4, or more children? |
1
2
3
4
More than 4
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* Have
you ever been arrested for any type of crime? |
YES
NO
|
* Have
you ever been treated by a psychiatrist or psychologist? |
YES
NO
|
* Are you presently under
circumstances that would limit or prevent you from performing a complete
range of activities? (e.g. lifting, kneeling, bending, running, jumping,
swimming, or dealing with stressful situations? |
YES
NO
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If yes to any of the three
above questions - please explain here: |
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* Do
you own an automobile? |
YES
NO
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If yes please describe
your vehicle |
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Driver's License #
and state? |
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* Have
Insurance? |
YES
NO
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Do you feel confident
enough in your driving skills to transport children/adults in an automobile? |
YES
NO
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* Have
you ever been convicted for a child or other crime? |
YES
NO
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* Have
you ever been brought into the police station for anything? |
YES
NO
|
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EDUCATION
Please include dates, schools, graduation year, training programs
attended, diplomas or certificates and child care experience. |
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EMPLOYMENT HISTORY PAST
FIVE YEARS - MOST RECENT EMPLOYER FIRST:
Employer: Supervisor: Address: Telephone: Dates Employed: Reason Terminated: |
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PLEASE LIST A MINIMUM
OF 5 REFERENCES THAT ARE CHILD CARE OR INDUSTRY RELATED:
(people that have seen you with children or in your industry that
can attest to your skill. NOT RELATED IF POSSIBLE i.e.; co-worker,
client, someone in your same industry) |
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LIST HERE A MINIMUM OF
5 PERSONAL REFERENCES NOT RELATED, WHO HAVE KNOWN YOU FOR 6 TO 10
YEARS, AND NOT THE SAME AS YOUR CHILD CARE/INDUSTRY RELATED REFERENCES;
(i.e.; friends, neighbors, teachers). Include phone numbers where
they can be reached during 9:00am - 5:00pm Monday - Friday. |
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*
Please write about yourself; size of your family, where you grew up,
your personality type, why you want to become a Nanny/Provider, and
what your goals are for the next 5 years.
( type as much text as you would like ) |
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* Born
where? |
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* Grew
up where and how many years there? |
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* How
long at your present address? |
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* Where
are your parents now? |
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* What
have your parents done for employment ? |
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* What
do your parents do for employment ? |
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* Tell
us about your home life, was it good? |
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* How
did your family spend free time? |
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How many brothers do you
have? How old are they? |
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How many sisters do you
have? How old are they? |
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What are they doing now
(school, etc.)? |
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* Do
you have a significant other and what does he or she do for employment? |
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* What
kind of values did your parents instill in you growing up? |
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* Describe
your personality to someone who doesn't know you? |
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* Can
you make a years commitment? |
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* Describe
the ideal situation for your employment. |
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How old are the children
that have been in your care? |
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Please tell us what
kinds of activities you like to do with children? |
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* What
qualifications do you feel you can offer a position? |
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* Describe
the speciality that you offer in your field of work. Example: what
type of food you prepare, what type of grounds work, etc... |
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PLEASE
LIST ALL OF YOUR ADDRESSES FOR THE PAST SEVEN YEARS,
Beginning with present address & working back. (include street,
city, country and state) |
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