Date: Name: Address: City, State & Zip: Email: Home Phone: ( ) Cell: ( ) Birth Date: Social Security No.: 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? Do you have experience caring for newborns? Do you have any experience with premature babies? 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? Driver's License no.: State: Year,Make and Model of vehicle: License Plate no.: Car Insurance Company: Insurance coverage: Policy no.: Have you ever had a D.U.I? 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.