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First Name

Last Name

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Do you smoke? Please note: childcare is a non-smoking industry Yes No

Do you have a valid driver's license? Yes No

State issued State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming OTHER

Do you have own and drive a dependable car? Yes No

Car Make

Car Model

Year Car Made Year 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

Are you CPR and First Aid certified? Yes No

Date of Certification

Can you swim? Yes No

Do you feel comfortable taking children swimming? Yes No

Do you feel comfortable transporting children in your car? Yes No

What about the parent's car? Yes No

Do you have at least two years of child care experience? Yes No

Current Occupation

Are you currently employed? May we contact your current employer?

Do you have any medical concerns?

Do you have children?

Are you comfortable around animals?