First Name:
Last Name:
Address 1:
Address 2:
City:
State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC
Phone:
Email Address:
Position Applyied For:
Are you citizen of U.S.? Yes No
Are you legally authorized to work in the United States? Yes or  No
Have you ever been convicted of a felony? Yes or  No
If yes, please explain.

Do you have a driver's license? Yes or  No
Do you have a passport? Yes or  No
Country issued

Employment History

Employer
Address
Phone
From (MM/YYYY) To (MM/YYYY)
Position
Responsibilities:

Salary
Supervisor/Manager
Reason for Leaving

Employer
Address
Phone
From (MM/YYYY) To (MM/YYYY)
Position
Responsibilities:

Salary
Supervisor/Manager
Reason for Leaving

Employer
Address
Phone
From (MM/YYYY) To (MM/YYYY)
Position
Responsibilities:

Salary
Supervisor/Manager
Reason for Leaving


References

Full Name
Relationship
Phone
Address

Full Name
Relationship
Phone
Address

Full Name
Relationship
Phone
Address

Education

High School
Address
From (MM/YYYY) To (MM/YYYY)
Did you graduate? Yes or  No
Degree
College
Address
From (MM/YYYY) To (MM/YYYY)
Did you graduate? Yes or  No
Degree
Other
Address
From (MM/YYYY) To (MM/YYYY)
Do you graduate? Yes or  No
Degree

Cetificates


List any skills that you would like to mention.


Submit a copy of your resume.

MEDICAL INFORMATION

In order to assure safe childcare, we must know about your medical and psychiatric conditions that could affect your ability to perform the job. Are you presently suffering from any communicable diseases that could be transmitted to a child you are caring for? 
Yes or  No
If yes, please explain:

Are you presently taking any medications, prescribed or not, which affects your judgment, coordination, levels of alertness and ability to respond to an emergency? Yes or  No
If yes, please explain:

Do you have any physical condition that might impair your ability to perform any reasonably required physical act normally required in the care of children? Do you have any mental condition that might impair or prevent your ability to protect a child from harm or that could impair your judgment?
Yes or  No
If yes, please explain:


DISCLAIMER AND SIGNATURE

By signing below, I certify that my answers are true and complete to the best of my knowledge.If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. Signature: Date:

EMPLOYMENT QUESTIONAIRE

I have experience caring for the following (check all that apply):
Newborns
Infants
Toddlers
School Age
Teenagers
Singleton
Twins
Triplets
Preemies
Child with disability
No experience
Other 

I have past experience as a: (check all that apply)
Nanny
Travel Nanny
Baby Nurse
Newborn Care Specialist
Teacher
Tutor
No past experience
Other: 

I have been certified and/or licensed as: (Check all that apply)
Nanny
Newborn Care Specialist
RN
EMT
LPN
Physician’s Assistant
Teacher
Special Education Teacher
Lifeguard
Psychologist
Social Worker
Learning Disabilities
Not certified
Not licensed
Other 

I am fluent in:
English
French
Other 

I am the following: (check all that apply)
Drinker
Smoker
Carnivore
Vegetarian
Vegan
Kosher
Other 

Allergies to the following:

I would be willing to work with the following families:
Traditional Family
Single Parent Family
Mother at home
Father at home
Divorced family
GLBT home
Custodian/Guardian home
All of the above
Other: 

I would help care for: (Check all that apply)
Singleton
Twins
Triplets
Other: 

I am available to work: (Check all that apply)
Full-time
Part-time
Day
Night
24-hour care
I am available to begin work:
I have a total of     years of childcare experience.

Please list all child/infant-related courses that you have taken:

Why do you like working with children?

What do you like most and least about being a childcare provider?

Tell us about yourself (hobbies/interests):