Provide us with the following information and we'll get
in touch with you ASAP.
Please provide information for the hours,
which you are available for work. Please be
specific as to what hours you are available
If you are a student, what school do you
Are you CPR or First Aid Certified?
Can you provide documentation of your
Please list names and dates of
Are you legally able to work in the U.S.?
If you drive and own a reliable car, what
Make & Model?
If you have a valid driver’s license, what
is the issuing state and license number:
Social Security Number (to conduct
Date of Birth:
Are you comfortable around animals?
What animals would prevent you from taking a
referred job at a Clients home?
Do you have any medical conditions that
would impact how you perform the job?
Can you swim?
Do you feel comfortable taking children
swimming if the opportunity became
How many children are you comfortable
handling in a six hour period?
What do you like most about working with
Please list most current school/institution
Diploma / Dreegree:
Have you participated in any volunteer work
that you would like us to know about?
If Yes, tell us about it:
Please start with your most recent employer:
Salary or wage per hour:
Reason for Leaving:
2nd to Last Employer:
Do you have at least two years of child care
Please explain your child care experience
Personal and Professional References
Please provide three child care related
By checking this box, you agree that the
information provided here is accurate to the
best of your knowledge.
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