Please provide the information below to allow us to understand your background and provide the best match with a client family:

Contact Information:

First name	Middle initial
Last name:
Address:
Home Phone:
Cell/Other Phone:
Email:
Are you at least 18 years of age and eligible to work in the US?:	Yes No

Certifications/Skills:

Are you CPR certified?:	Yes No
CPR expiration date:
Are you First Aid certified?:	Yes No
First Aid expiration date:
Are you willing to become certified/keep your certifications up to date?:	Yes No
Can you swim?:	Yes No
Are you certified in Lifesaving?:	Yes No
Lifesaving expiration_date:
Foreign languages spoken:
Do you enjoy cooking?:	Yes No
Can you prepare simple menus?:	Yes No

Personal History:

Do you have experience working with special needs children?:	Yes No
If yes, please tell us more:
Do you have experience working with mildly ill children (colds, fevers, food allergies, etc.)?:
	Yes No
If yes, please tell us more:
Have you ever been convicted of a felony?:	Yes No
If yes, please explain:
Have you ever been convicted of child or sexual abuse?:	Yes No
If yes, please explain:

Driving Experience:

Do you have a driver's license?:	Yes No
Number of years driving:	None 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years or more
Do you have full coverage auto insurance?:	Yes No
Have you ever had a driving violation or traffic ticket?:	Yes No
If yes, please explain:
Have you ever been convicted of driving under the influence (DUI)?:
	Yes No
Have you ever been in an accident while driving?:	Yes No
If yes, please explain:
Has your license ever been revoked or suspended?:	Yes No
If yes, please explain:
Do you have a safe/reliable vehicle?:	Yes No
If so, what is the year/make/model:
Are you comfortable transporting children in your car?:	Yes No
Do you require the use of your employer's vehicle to transport children?:
	Yes No

Health Information:

Do you smoke?:	Yes No
Would you work in a smoking environment?:	Yes No
Do you take illegal drugs?:	Yes No
Have you ever been convicted of a drug- or alcohol-related offense?:	Yes No
Are you taking any medications that may affect your ability to perform childcare duties?:
	Yes No
If yes, please explain:
Do you have any physical or medical conditions that could affect your ability to perform childcare duties?:
	Yes No
If yes, please explain:
Are your immunizations for childhood diseases up to date?:	Yes No Not sure
If no or unsure, please explain and note which immunizations you have not received:
Are you willing to submit to or provide the results of the following?:
Drug Screening Test:	Yes No
Tuberculosis Test:	Yes No

Emergency Contact:

Whom should we contact in the event of an emergency?:
Name:
Phone:
Address:
Relationship to you: