- Please provide the following demographic information:
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| Legal
Name (First, Middle and Last) |
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| Street Address |
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| City |
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| State/Province |
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| Zip/Postal Code |
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| How did you hear about Parent's Time-Out?: |
Did you call from an ad (what did the ad say) or were you
referred by a friend (what is your friends name), phone book, etc.
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| First Phone |
example: 480-333-5678 |
| Second Phone |
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| Phone Notes
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| E-mail |
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| Today's Date |
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Do you have a child of your own to take with you to work?
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If yes, please list sex of child and month and year born (boy, 10/98) |
| N/S Cross Street |
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| E/W Cross Street |
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Location Notes
(how far will you drive)
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- Please tell us the following information about what you are looking for in
a job:
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When can you start?
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Mon-Fri Daytime Availability
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(families won't call you for times that you don't list -- so,
if you are flexible on times - you must indicate that. Don't say that you
want to work 8a-5p if you are willing to work earlier or later than that;
instead say that you can work 8a-5p but are flexible on the start and end times,
etc.)
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Eve, Weekend & Overnight Availability
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| Future Changes to Schedule over the next year |
(are you moving, taking any classes,
going on vacation, etc)
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| Part or Full-Time: |
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# of Hours of work that you would like to work
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| Live-In or Out |
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Are you looking for long or
short-term work?
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Long-Term is defined as one year or longer.
If Short-Term, please specify why and when you will
need to stop working.
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Salary and Terms expected
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Please list the "gross" wages that you expect and not the "net."
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Would you prefer to be paid in cash or with a payroll
check?
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If you make more than $1,400.00 in a calendar year with the same family, that
family is obligated to pay employer taxes and Unemployment Insurance.
Claiming that you are an "Independent Contractor" is not legal and can lead to
action for both you and your employer.
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Do you have a valid
Driver's License
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Driver's
License
State
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Do you have any
Driving Violations or have you ever been convicted of a crime:
Be specific - we will be checking.
If none - please say
so.
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| Vehicle Information: |
Will you transport the kids in your own vehicle |
| What type of Vehicle do you drive? Does it have A/C? How many car seats can you
safely accommodate?: |
| Is your vehicle Insured and Registered? |
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| What is your Marital Status? |
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| Who should we contact in the event of an Emergency? (include phone numbers) and
what is their relationship to you: |
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What cities & states have you lived in during the last 10
years?
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(what were the months and years that you lived in each city,
state?)
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Do you have any Allergies to animals or anything else that
might be a household?
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Do you have any medical conditions that would impact how
you perform your job:
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| Do you have CPR/First Aid training? |
When does it expire?
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Do you have any other Training related to children?
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This is in addition to your education and experience - which will
be listed later. |
| Do you Swim |
Do you Smoke |
| Please describe your personality: |
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| What are your hobbies: |
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| What are your strengths: |
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| What are your weaknesses: |
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| Please describe your physical appearance (do not include anything that might be
discriminatory or indicate your race, ethnic background, nationality, etc.): |
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| Please describe visible tattoos or body piercing(s): |
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| Please describe your overall health and fitness, including how often you engage
in physical activity each week: |
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- Please provide the following information regarding your background:
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Ages of children that you have cared for:
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Years of Experience with children
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Please designate how many years are professional (nanny, day
care Montessori, etc.) and how many years are "baby-sitting." |
| Do you prefer active or more quiet children? |
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| Will you work in a home with a parent at home or in a home office? |
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| Would you travel with a family? |
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| What form of discipline do you use with children? |
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| What are your favorite activities to do with children? |
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Your Education
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(include years attended or date of degree/diploma for high
school & post high school education - but do not exceed 255 typed
characters/spaces or you will receive an error when you submit your
application.)
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Languages Spoken/Understood
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| Special Needs Experience |
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| Why do you want to work with children? |
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| What are your future plans, where will you be five years
from now? |
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- Please provide the following personal information to be used in conducting
our background search (criminal, wants and warrants, driving record
and social security trace). If you do not feel comfortable submitting this
information here, just leave it blank and you can provide it when we contact
you by telephone.
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Date of Birth
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Social Security Number
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D/L Number
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Other Names (maiden, etc.)
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| Please give us a general statement covering your
child care or baby-sitting experiences (include parenting and helping with
siblings) |
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- Please list your employment and/or child care. For each
Employer list (1) the employer's name, (2) their telephone number,
(3) your position there, (4) a description of your job duties, (5) if child
care list the sex and age of each child, (6) the dates you worked there,
(7) your wages and (8) your reason for leaving and how much notice you gave.
- We need 7-10 years of employment history. You
may put more than one employer into each box if you need to and we will
split them internally when we process your application. If your employment is not related to child care,
then you will also need to list at least three child care or baby-sitting
references in addition to your employment. You may use the last box
for this purpose - again combining all into one box is fine as we can split
them up internally.
- Please type in continuous lines without inserting line breaks. Use a
semi-colon (;) or period (.) between items, rather than referring to each item
according to it's numerical value (as listed above).
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| Employer #1 |
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| Employer #2 |
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| Employer #3 |
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| Employer #4 |
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Employer #5 or
Child Care References |
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- Congratulations you're done - please click the 'Submit
Application' button below to send
your application. You will be taken to the Fair Credit Reporting Act
form. Print this form, sign it and fax it to us at 480-460-1200 (or
480-422-4378).
- You will be contacted by a PTO Recruiter within
a few days to review your application and answer any questions that you may
have. Thank you!
- By Clicking on the Submit Application button you are agreeing that all of
the information provided is true and correct to the best of your abilities.
You are also agreeing that no information has been withheld, altered or
presented in a misleading fashion. And you are authorizing PTO to
conduct a background check.
SUBMIT:
RESET:
If you do not receive a page saying '"Fair
Credit Reporting Act (FCRA) Authorization Form" for your application -
your application was not submitted properly. Please come back to this screen by
holding down the "ALT" key and pressing on the backward arrow key. Make
any necessary corrections (as noted by a field error) and
then press the submit button again.
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- If this form was filled out by a PTO Recruiter please
complete this section. Thank you!
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| Interviewer Impressions |
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| Interviewer: |
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