Name:

Date of Birth:

Address:

Landline Telephone:

Email Address:

Cellular Telephone:

1.

How long have you lived in this community?

2.

How many people live in your home?

   (Please give details below)

NAME

D.O.B

RELATIONSHIP

SCHOOL / WORKPLACE

WHEN AT HOME

3.

How long have you lived at this address?

4.

Is the home owned or rented?

owned rented

5.

Do you care for other children on a regular basis?

yes no

6.

What is your previous/current occupation?

7.

Are you involved in any community groups? (e.g. Plunket, Parents Centre, School, Church, etc)

8.

Have you ever applied, or become a volunteer or employee for any other Family Day Care Service?
(Details Please)

9.

Is your property fully fenced, or is there a fenced area suitable for children to play?

yes no

10.

How does your family feel about you caring for other children in your home?

11.

What experience do you have with children?

12.

Do you have any Early Childhood qualifications? (Details please)

13.

Do you or your children attend any Early Childhood Service? (current and previous details please)

14.

Are you in good health?

yes no

Are you on any medication?

yes no

If yes what is the medication for?

Do you or your family have any physical or mental health problems?

yes no (if yes give deails below)

15

Are you a smoker?

yes no

Is anyone else in your home a smoker?

yes no

Regulations require us to provide a smoke free environment (including outside areas) when children are in care on the property. How would you provide this atmosphere?

16.

Do you have any pets? (details please)

yes no

How do they relate to children?

Are you willing and how would you restrain pets while children are in care?

17.

Do you have a current Drivers License?

yes no

License Number

18.

Do you have a motor vehicle with a current registration and warrant of fitness?

yes no

If yes, what is the registration number?

Is your vehicle fitted with seatbelts in both the front and rear seats?

yes no

19.

What sort of care can you offer? (please tick appropriate boxes)

PART TIME ONLY

FULL TIME

WEEKENDS

SCHOOL HOLIDAYS

UNDER 2's

OVER 2's

SPECIAL NEEDS

BABIES

20.

What experiences and equipment would you provide for the children in your care?

21.

Please tick any of these basic play activities you can provide

Outdoor Play

Multi/Bi-Cultural

Group Activities

Indoor Play

Dramatic Play

Finger Plays

Music and Movement

Nonsense

Dough

Books

Sand

Nature

Maths

Puzzles

Carpentry

Visits

Songs

Solitary Activities

Water

Art/Creative

Puppets

Blocks/lego/duplo

Science

Clay

Instruments

Messy Play

Cooking

22.

What limits do you place on television viewing?

23.

How would you manage children's behaviour?

24.

Why do you wish to become a Caregiver for Northland Homebased Childcare Services?

1.

Name

Address

Landline Telephone:

Cellular Telephone:

2.

Name

Address

Landline Telephone:

Cellular Telephone:

3.

Name

Address

Landline Telephone:

Cellular Telephone: