Child
Care
Provider
Application
for
The
Nanny
Club
Date:
Name: Address: City, State & Zip: Email: Home Phone: ( ) Cell: ( ) Birth Date:
Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday:
Desired Starting Wage:
Place of Employment: Start Date: End Date: May we contact this employer: Name: Phone: ( ) Place of Employment: Start date: End Date: May we contact this employer: Name: Phone: ( )
Do you have any experience being a child care provider? If yes , please explain. Do you have experience caring for newborns? If yes, please explain. Do you have any experience with premature babies? If yes, please explain. Do you have children of your own?
What is your highest level of education? If you are currently in college or have attended college in the past, list your area of study? Have you ever taken any classes or recieved any training (in high school, college or independently) dealing with children or the child care occupation? Do you speak any foriegn languages?
What are your plans or goals for the future?
Are you CPR certified? Are you trained in first aid? Do you have a child care sheriff's card?
Have you ever been convicted of a crime? If so, please explain.
Do you smoke?
Name: Phone no.: Relationship: Name: Phone no.: Relationship: Name: Phone no.: Relationship:
After submitting this application you will be transferred to a
child care questionnaire. Please complete and submit the
questionnaire.