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East Green Childcare Services

Carers Registration Form
General Information
Name: Maiden Name:
Home Address: Work Address       (if live in):
Home Tel No: Work Tel No:
May we contact you at work using first name terms? YesNo
Fax No: e-mail:
Date of Birth: Age:
Religion: Nationality:
Marital Status: Dependants:
Secondary Education
Name and address of Secondary School: Attended From:
To:
List Subjects with Grade / Level and date obtained
Further Education
Name and address of College: Attended From:
To:
List Subjects with Grade / Level and date obtained
Your Health
Do you suffer from any allergies? YesNo
Do you smoke? YesNo
Do you swim? YesNo
What is your swimming ability?  
Have you ever received psychiatric treatment? YesNo
Please state how many days off sick you have taken in the last year?  
Do you have any dietary restrictions? YesNo
Are you a vegetarian / vegan? YesNo
Would you be prepared to work for a non-vegetarian family? YesNo
If you are a non-vegetarian, would you be prepared to work for a vegetarian family? YesNo
Your Work Requirements
Please indicate which positions you would consider:
Nanny Parent's Help After School Care
Maternity Nurse Nanny/Housekeeper Part Time
Daily Special Needs Nanny Babysitting
Emergency Nanny Temporary Occaisional
Nursery Work Full Time Live In
Please state your preferred position  
Please state the hours you are prepared to work:  
Please state the date you become available:  
Are there any dates you are not available in the next 6 months?  
Please give dates available if on a temporary basis:  
Are you prepared to work weekends? YesNo  
Are you prepared to work flexible hours? YesNo  
Are there any locations you are not prepared to work? YesNo
Would you consider working abroad? YesNo
Salary required, £ net per week:  
What is the maximum number of children you would care for?  
What age group do you prefer to care for?  
Do you have experience of caring for children with special needs? YesNo
Do you hold a First Aid Certificate? YesNo  
Expiry Date:  
Transport Details
Do you hold a full U.K. driving licence? YesNo
Date of Issue:  
Do you have any endorsements? YesNo
Do you own a car? YesNo  
State the make, model and year:  
Are you prepared to use it in working hours? YesNo
Foreign Travel
Do hold a full British Passport? YesNo  
Would you be prepared to travel with a family? YesNo  
Do you speak any foreign languages? YesNo
Duties
Please indicate which duties you are prepared to undertake consider:
Nursery duties only Keep developmental records Keep a daily diary
Light housework Care for family pets Shared care (with Mother)
Cooking for family Sole charge  
Are you willing to work for a family with pets? YesNo  
Would you consider working for a smoking household? YesNo  
Are you willing to include visiting relatives in the children's day? YesNo  
Your Current Employer
Are you currently in employment? YesNo  
Does your employer know you are seeking employment? YesNo  
Notice period to be given:  
May we contact them prior to you giving notice? YesNo  
Employment History
Name & Address Dates Position Held May we contact them?
YesNo
YesNo
YesNo
YesNo
Hobbies and Interests
Any Other Information
Please use this space to provide any other information or circumstances the Agency may need to know:

I understand that I must inform East Green Child Care Services within 24 hours by telephone if I am offered a position.  If I accept the position I must inform the agency in writing within 5 days.

I Understand that this is a contract between myself and East Green Child Care Services.

I certify that the above information is correct.  I understand that all information given to myself with regards to prospective employers is confidential.
By Law, we are required to ask if you have any criminal convictions? YesNo
(Employment Agencies Act of 1973)
And Finally...
How did you hear about East Green Child Care Services?