Street Address: City: State: Zip:

Email Address (required):

Social Security Number: Day Telephone: Evening Phone:

Available Start Date: Hours Available: Days Available:

Desired Salary Range:

Are you 18 years of age or older?: Yes No: Do you smoke?: Yes: No: Opposed to Smoking?: Yes: No:

Are you eligible to work in the U.S.?: Yes No: Driver's License?: Yes No: State & Number:
Have you ever had a moving or driving violation or traffic accident (including tickets)?: Yes No:

If 'yes' list specifics:

Have you ever been arrested or convicted of a felony and/or a misdemeanor?: Yes No:

If 'yes' list specifics:

Have you ever been the subject of a substantiated complaint of child or sexual abuse?: Yes No:

If 'yes' list specifics:

Are you First Aid certified?: Yes No: Are you CPR certified?: Yes No: Do you swim: Yes No:

Are you certified in Life Saving?: Yes No: Are you willing to become certified in these programs?: Yes No:

If 'no' please list what programs in which you are NOT willing to become certified:

Are you comfortable caring for a child who is mildly ill?: Yes No: Do you need health insurance?: Yes No:

Please list any pets that you are NOT comfortable working around or living with:

The following questions are for live-in applicants only

Have you ever lived away from home before?: Yes No: If 'yes' how far, how long, and when?

Have you ever been responsible for the payment of your own living expenses? Yes No:

Have you ever had a checking account?: Yes No: Cooking Skills?: Yes No: Do Own Laundry?: Yes No:

Do you plan on bringing a vehicle?: Yes No: If 'yes' please list year, make, and model:

Medical Information

Do you have any medical conditions that would affect your ability to take care of children? Yes No:

If 'yes' please explain:

For each of the following, please indicate if you are willing to submit to, at no expense to you

Physical Examination: Yes No: Drug Testing: Yes No: T.B. Test: Yes No: H.I.V. Test: Yes No:

Have you been immunized against common childhood diseases?: Yes No:

If 'no' for which diseases have you NOT been immunized?:

Do you have any diet restrictions?: Yes No: If 'yes' please explain:

Do you have any current or history of emotional health problems?: Yes No: If 'yes' please explain:

Have you ever been recommended for an alcohol or drug rehabilitation or mental institution?: Yes No:

If 'yes' please explain:

Educational Background

Do you have a high school diploma/GED?: Yes No: Name of High School:

Name of College (if attended): Dates Attended: Major:

Degree/Certificated Achieved: Phone Number:

Please list any other certificates, licenses, or training:

Employment History

Current Employer (if a company list full company name): Supervisor's Name:

Street Address: City: State: Zip:

Employer Phone Number: Position Held: Employed Since:

Ending Salary: Reason for leaving?: May we contact?: Yes No:

List all child care references for the past five years

Company/Family Name: Employed From: Employed To:

Street Address: City: State: Zip:

Employer Name: Employer Phone Number: Position Held:

Ending Salary: May we contact? Yes No:

Reason for leaving?: Please describe responsibilities in detail:

Company/Family Name: Employed From: Employed To:

Street Address: City: State: Zip:

Employer Name: Employer Phone Number: Position Held:

Ending Salary: May we contact? Yes No:

Reason for leaving?: Please describe responsibilities in detail:

Company/Family Name: Employed From: Employed To:

Street Address: City: State: Zip:

Employer Name: Employer Phone Number: Position Held:

Ending Salary: May we contact? Yes No:

Reason for leaving?: Please describe responsibilities in detail:

Company/Family Name: Employed From: Employed To:

Street Address: City: State: Zip:

Employer Name: Employer Phone Number: Position Held:

Ending Salary: May we contact? Yes No:

Reason for leaving?: Please describe responsibilities in detail:

Personal, Character, or Professional References

Name: Relationship: Phone Number:

Length of Time Known:

Name: Relationship: Phone Number:

Length of Time Known:

Child Background/Information

Ages of the children you've cared for - Youngest: Oldest:

Please list the ages you have most and least experience with - Most: Least:

Age you started caring for children: Did you care for siblings?: Yes No:

Do you have experience working with special needs children?: Yes No:

If 'yes' please explain:

Have you had to handle an emergency of any kind?: Yes No:

If 'yes' please explain:

Household Staff

What Household Management or Housekeeping experience to you have?:

Personal Assistants

What executive or personal assistant skills do you posess?:

Please send a current resume in a Word.doc to Machelle@SolutionsHomeStaffing.com

I CERTIFY THAT I HAVE ANSWERED ALL THE QUESTIONS ON THIS APPLICATION ACCURATELY AND TO THE BEST OF MY KNOWLEDGE. I HAVE NOT WITHHELD ANY INFORMATION WHICH WOULD CAUSE THE INFORMATION GIVEN ABOVE TO BE
MISLEADING. IN THE EVENT OF MY EMPLOYMENT AS A RESULT, IN FULL OR IN PART, FROM THE INFORMATION CONTAINED ON THIS APPLICATION, I UNDERSTAND THAT ANY INACCURATE OR MISLEADING INFORMATION IS GROUNDS FOR IMMEDIATE TERMINATION OF EMPLOYMENT.

I certify that I have read and agree to this statement:

Date: