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Please provide your CONTACT INFORMATION
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* Name:
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* Address: (line 1)
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* Day Phone:
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Evening Phone:
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Address: (line 2)
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Cell Phone:
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Fax:
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* City:
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* State:
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* Zip:
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* E-mail: (correct email format required)
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How did you hear about us?
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What type of job are you seeking? |
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Type of Position (Check all that apply)
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Work arrangement (Check all that apply)
Long Term (3 or more months)
Short Term (One to twelve weeks)
On-Call (occasionally)
Would you care for:
Twins -- Triplets--- Bedridden-- ADD--
Handicapped-- Alzheimer's-- Dementia-- Emotionally Disturbed--Down's Syndrome--
Cerebral Palsy-- Hearing Impaired-- Blind-- Asthma-- Multiple Disabilities-- Medical Illness-- Diabetics--
Other: Do you speak a foreign language?
Yes No
If so, which ones and how fluent?
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Date available:
Number of references:
Total years of caregiver experience:
What do you like most about being a caregiver?
How many persons or children have you cared for at one time?
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TRAINING BACKGROUND
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Check the training you have taken:
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Please describe other types of experience or things for us to know you better
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This form is intended to provide basic information so we can better assist you. Submitting this form does not confirm, guarantee, or schedule employment through Bay Area 2nd Mom, Inc.
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