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Employment Application

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Contact Information:
Name:
Home Telephone Number:
Mobile Telephone Number:
Email Address:
Address:
City / Town:
Postal Code:
Number of Years at Residence:
Type of Home (Apt, Townhouse, etc.):
Previous address if less than 5 years at current address:
Rent or Own Home?:
Personal Information:
Date of Birth:
Languages Spoken:
Do you have a driver’s license?:
Driver's License #:
Auto Insurance Company:
Liability Coverage Amount:
Family Members:
Marital Status:
Spouse/Partner's Name:
Number of Children at Home:
Child's Date of Birth:
Child's Date of Birth:
Child's Date of Birth:
Child's Date of Birth:
List Any Other Persons Living at Home:
Do you or does anyone smoke in your home?:
If so, please advise who smokes:
Type of Pets at Home:
Are the Vaccinations up-to-date?:
Do you (or anyone in your household) have a criminal record?:
If yes, please give details:
Background Information:
List any previous daycare experience:
List any childcare courses taken:
Have you completed a First Aid or CPR course?:
If so, when?:
Are you currently providing daycare or are you listed with an agency?:
If you are currently caring for daycare children, provide names and ages:
Home Environment:
Does your home have a basement apartment with tenants?:
Has your home been child-proofed?:
List the areas of your home that will be available to children:
List any childcare equipment that you may have available to use (e.g. toys, playpen, high chair, stroller, etc.):
Are the outdoor areas of your property fenced?:
If not, will they be?:
Do you have a swimming pool?:
Questionnaire:
Are you interested in full time or part time?:
Which days and/or hours?:
Age Group Preference:
Do you plan on using a car to transport children?:
How did you hear about Hopscotch?:
References:
Please provide two references that are unrelated and not living with you, preferably one being work related
(include name, daytime tel. number and relationship):
Reference #1 Name & Relationship to you:
Reference #1 Daytime Tel:
Reference #2 Name & Relationship to you:
Reference #2 Daytime Tel:
Are you willing to have fire, health and police checks?:

I certify that the information I have supplied on this application is correct, and agree that Hopscotch Home Daycare Agency may further investigate or verify this information and contact the references listed above in connection with my proposed relationship with Hopscotch Home Daycare Agency.


Hopscotch Home Daycare Agency
Tel: 289.466.1111*
Email: info@hopscotchdaycare.com
Facebook: www.facebook.com/hopscotchdaycare


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