Employment Application Employment Application First Name * Last Name * Date of Birth * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal How long at current address? * Mobile Phone * Email Address * Are you a U.S. Citizen? YesNo Can you prove you have a legal right to work in the U.S.? YesNo Background Information Alias (all other names used) and/or maiden name? Do you have a Colorado driver's license? YesNo Driver's license number Other states or countries you have lived in? Have you ever been convicted of a crime? YesNo If so, please explain Do you own a vehicle? YesNo Year Make Model Position Desired Full-time or Part-time? Full-timePart-time Availability Date available to Start Do you have any situation in your life that could change your availability? YesNo How far are you willing to travel? Less than 10 miles10 miles to 25 miles25 to 50 miles50 miles or more Preferred cities to work? Compensation Requirements (Note: Salary levels depend on experience on education Desired hourly rate Are you willing to negotiate? YesNo Education High School attended Date graduated or attended College attended Date graduated Major Other Certifications Are you a Doula? YesNo Are you a newborn care specialist? YesNo Are you CPR certified? YesNo Are you first aid certified? YesNo Are you bilingual? YesNo If yes, what languages? Do you have any experience working with a special needs child? YesNo If yes, please explain Do you have experience with twins? triplets? YesNo Do you have children? YesNo If yes, what ages? Childcare Employment Please tell us about your childcare experiences Family Name Address Phone Number of children you cared for Ages of child(ren) when employment started Employment Start Date with this family Employment End Date with this family Family Name Address Phone Number of children you cared for Ages of child(ren) when employment started Employment Start Date with this family Employment End Date with this family Childcare References NOTE: You must have three (3) childcare references, other than family and more than as an occasional sitter Reference #1 Name Address Date Started Date Ended Phone Reference #2 Name Address Date Started Date Ended Phone Reference #3 Name Address Date Started Date Ended Phone Personal References (List two (2) personal references other than family) Reference #1 Name Length of Relationship? Relationship to you Contact phone number Reference #2 Name Length of Relationship? Relationship to you Contact phone number Health Information How is your general health? Do you smoke? YesNo Do you have any physical disability which would prevent you from performing specific kinds of work? YesNo If yes, please explain the work limitations Are you now, or have you been treated for a drug or alcohol habit? YesNo If yes, please explain Do you have or have you ever been told that you have allergies (i.e., to pets)? YesNo If yes, please explain Have you had TDAP injection within last 10 years? Please provide documentation upon request. YesNo Did you have a flu shot this year? Please provide documentation upon request. YesNo Have you received a Covid-19 vaccination? * YesNo Have you received a booster shot? YesNo I certify that the information I have furnished herein is true and accurate. Today's Date Signature of Applicant * reCAPTCHA If you are human, leave this field blank. Submit Connect with us on LinkedIn
