CHILDCARE SOLUTIONS
Care Provider Registration & Application
Date:
First Name:   Last Name:     Maiden Name:
Street Address:   City:   State:   Zip Code:  
Home Phone:   Cell Phone:   Email:  
Other Phone: Emergency Contact Name: Emergency Contact Phone:
Driver's License: State Issued: Date Of Birth:    
Car Make/Model/Year: Insurance Company:

My Children:       I Need To Bring My Child With Me To Work:
Gender: Name: D.O.B.:   At Home:
Gender: Name: D.O.B.:   At Home:
Gender: Name: D.O.B.:   At Home:
Gender: Name: D.O.B.:   At Home:
I Smoke:       These Pets Live In My House:
Education, Training & Experience...
High School Graduate?
Year:
First Aid: CPR:
College Graduate?
Year:
School:
Major:
Degree:
Post Grad Degree?
Year:
Details:
Nanny School Grad?
Year:
Nanny School Name:
Education Comments:  Languages Spoken:
  (Courses Taken, Certificates Earned, etc.)
My Cooking Skills Are:       My Swimming Skills Are:
I Have Experience Working With:
Newborns:
Infants:
Toddlers:
Pre-Schoolers:
Elementary Age:
Pre-Teens:
Teens:
Seniors:
Phys. Disability:
Learning Disability:
Describe Your Child Care Experience and Expertise:  

Describe Your Work Preferences:  

In general, a nanny will always prepare meals for the children and keep the children’s rooms & play areas clean and tidy:
Are you willing to take on any of the following Household Responsibilities?: please check all that apply...




I Have The Following Allergies:
I am NOT Comfortable Around These Pets/Animals: