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Employee Registration Form

Title

Employee Name

Address Line 1

Address Line 2

City

Zip Code

Home Phone

Business Phone

Cell Phone

Email Address

Type of Position Applying for?

Live In Live Out

Full-Time Part-Time

Do you have a Driver's License?

Yes No

Do you own a car?

Yes No

What is your legal status in the US

Marital Status

Children

Yes No

How long in the United States?

Education

Degrees

Languages Spoken

Are you qualiﬁed, licensed in any health, medical or related ﬁeld?

Do you smoke?

Yes No

Do you have allergies? If yes, please describe

Can you work with pets?

Yes No

Can you swim?

Yes No

Have you got CPR/First Aid Training?

Yes No

Have you ever been investigated, or arrested for a criminal offense? If yes, please explain

Have you ever been admitted to, or been a subject to an investigation for an act of child abuse, battering or molestation? If yes, please explain

Desired salary

Date available for employment

Please submit this form

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