Child Care Application

Name: Last

First

M.I.

Mailing Address:

Apt.:

D.O.B.:

City:

State:

Zip:

Phone:

Email:

Additional Contact #:

Social Security No.:

Have you ever been on this registry before? YesNo

If yes, when?

Have you ever been convicted of a felony, other than a traffic violation? YesNo

If yes, explain:

High School:

Address:

From: to

Did you graduate?: YesNo

Diploma:

College:

Address:

From: to

Did you graduate?: YesNo

Diploma:

Other:

Address:

From: to

Did you graduate?: YesNo

Diploma:

Do you have any physical limitations that will prevent you from performing daily tasks?: YesNo

If yes, please explain:

Do you smoke? YesNo

Do you own a vehicle? YesNo

Is the vehicle a: N/ACARSUVTRUCKVAN

Do you have car insurance? (Proof of insurance required)YesNo

Are you available: Full-timePart-timeOccasionally

Are you available: Mon-FriSat & SunHolidays

Please check any of the following shots/immunizations that you have received?Pertussis (aka Whooping cough)TB testHepatitis BTetanusInfluenza (Flu)

Emergency Contact

Name:

Phone #:

Relationship to you:

Email:

Name:

Phone #:

Professional Relationship:

Email:

Name:

Phone #:

Professional Relationship:

Email:

Name:

Phone #:

Professional Relationship:

Email:

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary

Ending Salary

Responsibilties:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference? YesNo

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary

Ending Salary

Responsibilties:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference? YesNo

Company:

Phone:

Address:

Supervisor:

Job Title:

Starting Salary

Ending Salary

Responsibilties:

From:

To:

Reason for Leaving:

May we contact your previous supervisor for a reference? YesNo