Child Care Application Contact Number (required) Email (required) Work Areas Rural AreasCitySmall Town Are you willing to work in the following in the above areas? Date of Availability Please enter the date that you'll be available. Expected Wage Personal Information Your Name (required) Address Date of Birth Martial Status Children How many children do you have? Ages Please give the ages of your children Status Home Child Care Provider Pilot or the Home Support Worker PilotOpen work permitLanded immigrantCitizen What is your status here? How long have you been here? Date of Arrival Experiences and Preferences Education Activities Story tellingStory readingBall gamesRacket gamesWalks or hikesCraftsBike ridingArtwork and colouringPuzzlesSwimming Check the activities that you enjoy doing with children. Ages of children cared for Infant (0-16 months)Pre-School (3-5 years)Toddler (17 months to 3 years)School Age (6 years and up) No. of children cared for at one time: How many years of caring for children: Interested in caring for children with special needs? YesNo Do you have experience with caring for children with special needs? YesNo Would you be interested in providing care for the following? ChildrenElderly Interested in working as: Full-timePart-timeCasual/On-call Do you smoke? YesNo Do you own a driver's license? YesNo Do you have access to a car? YesNo Do you rely on public transit? YesNo Do you know first aid training? YesNo Do you know CPR training? YesNo Are you willing to get the following: First Aid TrainingCPR TrainingPolice Background Check General Information Driving Record Cooking Skills PoorAverageGoodExpert Are you able to prepare any of the following cuisine? AmericanEuropeanChineseOther Can you swim? YesNo Are you allergic to pets? YesNo What languages can you speak? EnglishTagalogIlocanoVisayanCantoneseMandarinSpanishOther English is the major language in here. On a scale of 1 to 10, how do you rate your abilities: Verbal Communication Listening Comprehension Other Skills Employment History Employer #1 Name Employer #1 Contact Number Date of Employment Address May we contact this employer? YesNo Ages of children/elderly you cared for Reason for leaving Employer #2 Name Employer #2 Contact Number Date of Employment Address May we contact this employer? YesNo Ages of children/elderly you cared for Reason for leaving Employer #3 Name Employer #3 Contact Number Date of Employment Address May we contact this employer? YesNo Ages of children/elderly you cared for Reason for leaving Please answer the following questions briefly Behaviours Some common annoying behaviours are listed below. Please indicate on how the behaviour affects you, and explain how you handle this type of behaviour. Yelling Doesn't annoy meAnnoys me a littleAnnoys me a lot Running in the house Doesn't annoy meAnnoys me a littleAnnoys me a lot Playing with food Doesn't annoy meAnnoys me a littleAnnoys me a lot Throwing toys Doesn't annoy meAnnoys me a littleAnnoys me a lot Crying for parents Doesn't annoy meAnnoys me a littleAnnoys me a lot Saying no to everything Doesn't annoy meAnnoys me a littleAnnoys me a lot Refusing to eat certain foods Doesn't annoy meAnnoys me a littleAnnoys me a lot Insisting on helping you with everything Doesn't annoy meAnnoys me a littleAnnoys me a lot Wanting to do things their own way Doesn't annoy meAnnoys me a littleAnnoys me a lot Refusing to help clean up Doesn't annoy meAnnoys me a littleAnnoys me a lot Removing diapers Doesn't annoy meAnnoys me a littleAnnoys me a lot Do you agree to send the above information? I hereby swear that the above information is correct and authorize, Reliable Nanny & Caregiver Placement Agency to verify my information. Δ
