18 years of age or older?

Are you legally eligible to work in the U.S.?

Do you smoke?

If no, do you object to smoking?

Do you have a driver's license

Have you ever had a moving or driving related violation or traffic accident (including tickets)?

Have you ever been convicted of a felony and/or misdemeanor?

Have you ever been subject of a substantiated complaint of a child or sexual abuse?

Are you certified in First Aid?

Are you certified in CPR?

Do you swim?

Are you certified in lifesaving?

Are you willing to become certified in these programs?

Are you comfortable caring for children when they are mildly ill?

Do you need health insurance?

Are you applying for Live-in position?

Have you ever lived away from home before?

Have you ever been responsible for the payment of your own living expenses?

Have you ever had a checking account?

Do you have cooking skills?

Do you do your own laundry?

Do you plan on bringing a vehicle?

Do you have any medical condition that could affect your ability to care for children?

For each of the following, please indicate which ones you are willing to submit to.

Have you been immunized against the common childhood diseases?

Do you have any diet restrictions?

Do you have a high school diploma/GED?

Employment History

May we contact?

Personal, Character or Professional References



Childcare Background/Information

Ages of the children you have cared for

Please List The Ages You Have the Most and Least Experience With

Did you care for your siblings?

Have you had experience working with special needs children?

Have you had to handle an emergency of any kind?

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