Please provide the information below to begin the registration process:

First name:
Last name:
Address:
Home Phone:
Cell/Other Phone:
Email:
How many years of experience?:
Are you at least 18 years of age and eligible to work in the US?:	Yes No
When did your most recent professional childcare position end? (Month/Year):
How many hours per month did you work in your most recent professional childcare position?:
Education:	Some High School High School Diploma Two-Year College Degree Four-Year College Degree
Name of college (if any):
Have you ever worked in a daycare center or pre-school?:	Yes No

For California Applicants Only

Are you registered with TrustLine?:

Yes No

About yourself

Foreign languages spoken:
Do you have a valid Driver's License (some jobs may require you to drive)?:	Yes No
Do you smoke (some people may not want smoking in the home or around children)?:	Yes No
Preferred age of children you like to work with:
Are you currently employed?:	Yes No
Do you have a current CPR and/or First Aid certificate?:	Yes No
Do you have a car that you can drive to work (some work locations may not be accessible by public transportation)?:	Yes No
Have you ever been convicted of a felony or child abuse?:	Yes No
If yes, please explain:
Have you ever been convicted of driving under the influence (DUI)?:	Yes No

Preferences

Areas/Cities you wish to work in?:
How many children are you comfortable working with?:
What are your preferred days and hours of working?:
How many hours per week, including weekends, are you able to work?:
Are you willing to stay overnight for childcare?:	Yes No
What is the best method to reach you?:
Are you able to work with 6 hours of notice?:	Yes No
Why did you choose to be a nanny?:
What do you like most about your current job? What type of work environment would you most enjoy?:

References

Please provide contact information for 3 references
(2 professional and 1 personal):

Name:			Phone:
Name:			Phone:
Name:			Phone: