NAME		PHONE
ADDRESS		NAME of Community
EMAIL ADDRESS:
What type of home do you live in?		House Duplex Townhouse Apartment
Do you have a fenced yard?	Yes No	Do you or anyone in your home smoke?				Yes No
What are the closest schools to you?	Separate:	Public:
Do you have children of your own at home?		NUMBER: 0 1 2 3 4 5 6		AGES:
Are you open to any age of child?		No Yes
Are you currently employed?		Yes No	FT PT		Where:
Are you on social assistance?		Yes No

What days/hours are you available?

Times	MON	TUE	WED	THU	FRI	SAT	SUN
START
STOP

Would you ever be available on an evening or weekend?		Yes No
If married, is your husband employed?		Yes No
What shifts does he work?
Do you have any pets?	Yes No	If so, what kind?

Why are you interested in joining a family day home agency?

Have you applied for and worked with another day home agency?

Yes No

Do you have any work experience in childcare?

Yes No

What sort of activities would you plan with the children?

Do you have first aid?

Yes No

Could you provide 3 childcare references if needed?

Yes No

Do you own any equipment (plaY-yARD/ Highchair/ Stroller)?  

HOW DID YOU HEAR ABOUT US?

ANY OTHER RELEVANT INFORMATION YOU WOULD LIKE US TO KNOW?