Bay Area 2nd Mom, Inc. -Provider Interest Form



		Site search Web search

Caregiver Interest Form

Please note: Red asterix ( * ) indicates a required field. This is unified form for Child/Senior Care, please fill the corresponding fields to your interest only. Thank you.

Please provide your CONTACT INFORMATION

* Name:

* Address: (line 1)

* Day Phone:

Evening Phone:

Address: (line 2)

Cell Phone:

Fax:

* City:

* State:

* Zip:

* E-mail: (correct email format required)

How did you hear about us?

What type of job are you seeking?

Type of Position (Check all that apply)

Child Care Senior Care

House Manager Personal Assistant

Housecleaner Companion

Work arrangement (Check all that apply)
Long Term (3 or more months)
Short Term (One to twelve weeks)
On-Call (occasionally)

Live-In		Part Time
Live-Out		Full Time

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?

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?

TRAINING BACKGROUND

Check the training you have taken:

CPR Child Care

First Aid Senior Care

AED Disease Awareness

Please describe other types of experience or things for us to know you better

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.


		Home \| About Us \| Services \| Forms \| Testimonials \| Resources \| Contact Us © 2001 Bay Area 2nd Mom, Inc. All rights reserved.