Mollycoddlers Application
General Information
Full Name:
Age:
DOB:
Home phone:
Cell phone:
email:
Street:
City:
State:
Zip:
How Long?:
If less than 2 years previous address:
Street:
City:
State:
Zip:
How Long?:
Have you ever been convicted of a crime?
Emergency Contact Information:
Name:
Relation:
Phone:
Placement Preferences
When can you start?
Salary requested for F/T or P/T ($ per):
How many hours would you like to work per week?
What position are you applying for? (you may check more than one):
Live In
Full Time
Part Time
Temporary
Babysitting
Errands
What days and hours are you available? Please be specific:
Monday from
Tuesday from
Wednesday from
Thursday from
Friday from
Saturday from
Sunday from
Please check ages of children you are willing to work with and have experience with (you may check more than one):
Newborn (0-3mos)
Infant (4-12 mos)
Toddler (1-3 yrs)
Preschool (4-5yrs)
School age (6+ yrs)
All of the above
What is the maximum number of children you wish to care for?
Please check all you are willing to care for:
Twins
Triplets
Special Needs
Prior experience with twins, triplets, or special needs:
Are you okay working in a home with pets?
Any exceptions?
Please list areas of childcare in which you have had experience. (nanny, daycare, babysitting, camp counselor, church nursery, etc.)
Are you CPR certified?
First Aid certified?
Are you willing to certify if not current?
Yes
No
Do you smoke?
Yes
No
If yes, are you willing to refrain from smoking during work hours?
Yes
No
Do you swim?
Languages fluent in:
Housekeeping
Please list housekeeping duties you are willing to perform and if it is for child or entire family.
Are you able to travel with a family if necessary?
Yes
No
Do you have children?
Yes
No
What are their ages?
Will your children need to go to work with you?
Yes
No
Driving Information
Do you drive?
Yes
No
Do you own a car?
Yes
No
Car Make & Model:
If you don’t have a car how will you get to work?
Any moving violations or accidents? (please explain)
Education
High School:
City, State:
Years Completed:
Major/Degree:
Year graduated:
College:
City, State:
Years Completed:
Major/Degree:
Year graduated:
Other:
City, State:
Years Completed:
Major/Degree:
Year graduated:
Childcare and Employment History
Please start with your most current or recent job.
Please indicate type of employment:
Childcare
Other Employment
If childcare:
No. Children:
Ages:
From:
To:
Are you currently working here?
Employer:
Phone:
Job Title:
Reason for leaving or wanting to leave:
May we contact?
Yes
No
Please indicate type of employment:
Childcare
Other Employment
If childcare:
No. Children:
Ages:
From:
To:
Are you currently working here?
Employer:
Phone:
Job Title:
Reason for leaving or wanting to leave:
May we contact?
Yes
No
Please indicate type of employment:
Childcare
Other Employment
If childcare:
No. Children:
Ages:
From:
To:
Are you currently working here?
Employer:
Phone:
Job Title:
Reason for leaving or wanting to leave:
May we contact?
Yes
No
Please list 3 references that have first hand knowledge of your childcare experience.
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
Personal
List 3 characteristics that best describe your personality:
1.
2.
3.
What are your hobbies/special interests?
What activities do you enjoy doing with children? (be specific)
How would you soothe a crying infant?
You are caring for a 2 year old that begins to throw a tantrum. What do you do?
You are taking a 3 yr. old on an outing to the park. What should you pack to take with you?
Are you willing to submit to a full background check?
Yes
No
Signature of Applicant:
Date:
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