A Friend of the Family ::: Childcare & Eldercare Referrals

CAREGIVER GROUP CARE APPLICATION

* denotes required fields

*First Name:

MI:

*Last Name:

*Address:

*City:

*State:

*Zip:

*Home Phone:

*E-mail Address:

Mobile Phone:

Work Phone:

*Date you can start:

*Have you ever applied to A Friend of the Family before? Yes No

*Are you available every Sunday morning from 8am to 2pm for 3 months at a time? Yes No

Are you available 2 out of 3 of the following days from 8 am to 2pm for 3 months at a time? (check all that apply)
*Tuesday: Yes No *Wednesday: Yes No *Thursday: Yes No

What other times would you be available to work other group situations?

Day(s)	Times
	From	To

*Do you smoke?:

Yes
No

*Do you have your own transportation you can bring with you on the assignment? (If no, this will not disqualify you for group care assignments.):

Yes
No

*Are you age 19 or older?

Yes
No

*Are you legally able to work in the United States?

Yes
No

*Have you ever been convicted of a felony or misdemeanor or do you have any pending charges? Yes No
*If yes, please explain:

Employment History:
*Please complete this section in full. Incomplete work history may disqualify your application from further consideration.
List your recent (5 to 10 years) paid experience in childcare.
Please do not list any relatives.

Employer 1
Name of Employer:
Contact Person:		Contact Phone:
Contact Email:		Contact Phone2:
Place of Employment:		Dates of Employment:	from to
Position:		Duties:
Beginning Wages:		Ending Wages:
Number of Children:		Ages of children when you started:
Number of hours worked per week:		Hours worked per month:
Reason for leaving the job:		Please select one: You may contact my reference now You may contact my reference at a later time

Employer 2
Name of Employer:
Contact Person:		Contact Phone:
Contact Email:		Contact Phone2:
Place of Employment:		Dates of Employment:	from to
Position:		Duties:
Beginning Wages:		Ending Wages:
Number of Children:		Ages of children when you started:
Number of hours worked per week:		Hours worked per month:
Reason for leaving the job:		Please select one: You may contact my reference now You may contact my reference at a later time

Employer 3
Name of Employer:
Contact Person:		Contact Phone:
Contact Email:		Contact Phone2:
Place of Employment:		Dates of Employment:	from to
Position:		Duties:
Beginning Wages:		Ending Wages:
Number of Children:		Ages of children when you started:
Number of hours worked per week:		Hours worked per month:
Reason for leaving the job:		Please select one: You may contact my reference now You may contact my reference at a later time

Employer 4
Name of Employer:
Contact Person:		Contact Phone:
Contact Email:		Contact Phone2:
Place of Employment:		Dates of Employment:	from to
Position:		Duties:
Beginning Wages:		Ending Wages:
Number of Children:		Ages of children when you started:
Number of hours worked per week:		Hours worked per month:
Reason for leaving the job:		Please select one: You may contact my reference now You may contact my reference at a later time

Volunteer History:
List any Volunteer Experience with children such as girl or boy scouts, school volunteer, room mother, coach or swim teacher, teacher of music, dance, drama, and art, teaching Sunday School, working in church nursery, etc. where you had direct contact with childcare or elderly on an ongoing basis.
Please do not list any relatives or sources previously listed.

Volunteer Reference 1
Dates:	to
Name of Institution:		Contact:
Address:		City:
State:		Zip Code:
Contact phone:		Email:
Volunteer duties:		Ages of children:

Volunteer Reference 2
Dates:	to
Name of Institution:		Contact:
Address:		City:
State:		Zip Code:
Contact phone:		Email:
Volunteer duties:		Ages of children:

Volunteer Reference 3
Dates:	to
Name of Institution:		Contact:
Address:		City:
State:		Zip Code:
Contact phone:		Email:
Volunteer duties:		Ages of children:

Personal references: Please do not list any relatives or sources previously listed.

Personal Reference 1
Name:		Relationship:
Address:		City:
State:		Zip Code:
Email:		How well does this person know you?

Personal Reference 2
Name:		Relationship:
Address:		City:
State:		Zip Code:
Email:		How well does this person know you?

Personal Reference 3
Name:		Relationship:
Address:		City:
State:		Zip Code:
Email:		How well does this person know you?

Education	Name/Location	Graduated/ Completed?	Date of certification
High School:		Yes No
GED:		Yes No
Associates Degree:		Yes No
College:		Yes No
Post Graduate:		Yes No
Teaching Certificate:		Yes No
Certified Nursing Assistant:		Yes No
CPR Certified:		Yes No	Certificate is valid until:
First Aid Certified:		Yes No	Certificate is valid until:
Areas of study, skills, talents, experience or comments:

*Why do you think some children misbehave?

*What is the one thing you want the children to
take away after being with you in the nursery?

*I attest that all information I have provided is true and accurate to the best of my knowledge.

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