Personal Information   What COUNTY in New Jersey do you live in?     Name   Home Phone   Available to start   Cell Address Fax Number   City   Best Time to Call   State   Email   Zip         At this address how long?         Do you have kids?  Yes  No   Are you married? Yes   No   Date of Birth:       Are you a US Citizen? Yes  No    If No, do you have a current visa or greencard?  Yes  No   Approximate weight   Approximate Height   Length of commitment you are willing to make to family at this time?     Caregiver Experience   No  Yes Which do you desire to do? Childcare Elder   How many years of childcare experience do you have?     How many of eldercare?     CPR 1st Aid Training   Transportation Drive - have car   Drive - no car   Ride with another   Public Transportation Valid drivers license  Yes  No License State License ever been suspended or revoked? Yes  No If Yes, explain       Education High School Graduate  Yes  No College Graduate? Yes  No Are you currently a student?Yes  No What is your major?    When do you finish your degree?            Do you have children you need to bring with you?  Yes  No Rate your health  Excellent  Good  Fair  Poor Can you swim?  Yes  No  Smoker Yes No Do you drink alcohol?  On occasions only  Often  Rarely   You are seeking to provide for family (check all that apply):   Evening/Weekend Babysitter   Full Time 'Live In' Care    Part Time Care (less than 25hrs/week)   Summer Care/temporary   Part Time Noon/Eve Care   Mothers Helper 'Live Out'   Full Time 'Live Out' Care   Mothers Helper 'Live In'  Other   Emergency Care/temp  Elder Companion Care  Newborn Care    Willing to Provide         Extensive Housekeeping   Driving   Laundry Service   Cooking   Run Errands   Petcare    Will Administer Medicine With Permisson    Arts and Crafts    Homework Assitance    Eldercare     Childcare Experience (check all that apply)   Live In Nanny   Live Out Nanny   Babysitter   Tutor   Day Care Provider   Preschool Teacher Elementary Teacher   Foster Parent   Au Pair   Summer Nanny    Babynurse             Fee or desired salary (before taxes):   Do you have excellent verifiable non family caregiver references?    Yes   No Do you speak a foreign language?  Yes  No         If yes which one(s)?   Do you have experience with special needs children?  Yes  No   If Yes, what   What age do you prefer working with?    Have you ever been arrested?  Yes  No   If Yes, explain Have you worked through an agency to find employment before?  Yes  No Will you work in a home with pets?  Yes  No   If yes which pets do you prefer? Cats  Dogs   Both     What hobbies or interests do you have?   In three words how would you describe your personality?   I, confirm the above information is accurate to the best of my knowledge.  I understand any misrepresentation of facts on this application can be considered cause for discontinuation of Careful Caregivers referral service. Careful Caregivers is given the right to contact all references and solicit information about me and my previous job performance.  I understand information, as well as any supporting documentation, will be disclosed for review by potential employers.   I also agree to, as a requirement for inclusion in the Careful Caregiver referral service, to submit too a state and federal criminal and child abuse clearance.  I agree to allow US Information Search to process background clearances at the request of CC.  I  hereby warrant that  the above facts stated are true and complete and are made for the purpose of assisting me secure employment.     I have read the above and I understand that any misrepresentation of facts will disqualify me from Careful Caregivers Agency