Your Name (required)
Your Email (required)
Your Phone Number (required)
Current Address (required)
Date of Birth (required)
Place of Birth (required)
Do you have any family at your desired location of employment? Yes No
Work Permit Expiry
Months Employed on Live-In Program (according to ROE)
High School (Year Completed)
Post Secondary (Institution Name, Year Completed, Degree Obtained)
Childcare/Eldercare Training Courses
First Aid/CPR Certification Dates
Preferred location of Employment Edmonton St. Albert Sherwood Park Rural Calgary Other All
Date Available to start
How long are you willing to work for your future employer?
Please describe your current daily routine
Are you willing to work flex hours/days? Yes No Occasionally
Are you willing to work a split shift? Yes No Occasionally
Are you willing to baby-sit on weekends? Yes No Occasionally
Will you work in a single parent household? Yes No
Will you work with a stay at home mom? Yes No
Will you work with a parent that works from home? Yes No
Will you work with a child with special needs? Yes No
Are you capable of taking full charge of household and childcare duties while your future employer is away on business or vacation? Yes No
Do you like pets? Yes No
Have you experience caring for any pets? Yes No
If yes, what kind of pet(s)? What did you do with this/these pet(s)? Please describe
Do you have allergies? Yes No
If yes, what are you allergic to?
Are you medically and physically fit to work? Yes No
If no, are there tasks you are unable to do?
Do you have a driver’s license? Yes No
If no, are you willing to learn to drive and take driver‘s training courses? Yes No
If yes, what kind of licence? (i.e. international, Alberta)
If yes, how many month’s or years of driving experience do you have?
If yes, have you ever been in an accident? Yes No
Have you cared for Babies under 1 year old? Yes No
Are you comfortable caring for a newborn? Yes No
Are you familiar with the normal stages of milestones/development, for example, ages when infants should: Reach Sit Crawl Climb Cut Teeth
Do you have experience with any of the following: Changing Diapers Bottle Feeding Making/ preparing baby food Routine nap/ feeding times Preparing for outings with baby
If you selected “Preparing for outings with a baby” please provide an example
Have you cared for Children aged 1-3 years old? Yes No
Describe what learning activities you would do with a toddler (1-3)
Are you willing to read books on child development and childcare? Yes No
Are you familiar with safety issues affecting children of this age group such as: Climbing hazards Choking hazards Dangers of rough play
Are you familiar with the normal stages of toddler development, for example: Potty training Walking Speaking Proper nutrition Sleep patterns/ required amount of sleep Gross motor Fine motor
Are you capable of providing a child with age appropriate discipline? Yes No
Please describe how would handle behavioural issues?
Are you willing to escort your future employer’s children to school and extra-curricular activities by foot/bus or car? Yes No
Have you cared for children aged 3 – 5 years old? Yes No
Describe what learning activities you would do with a preschooler (3-5)
Are you familiar with the normal stages of development of preschool aged children? Proper nutrition Sleep pattern/ required amount of sleep Gross motor skills Fine motor skills Appropriate play
What outdoor activities would you do with children?
Have you cared for Children aged 5-12 years old? Yes No
If you have cared for children between the ages of 5 and 12, what activities did you involve the child in to help keep her active and occupied?
Would you be able to assist a child with homework? Yes No
Have you cared for Teenagers? Yes No
Do you feel you could manage and direct a teenager? Yes No
Are you able to take messages and provide instructions on the telephone in English? Yes No
Can you follow written instructions from an employer? Yes No
How would you rate your cooking abilities? Outstanding Above average Average Below average
Please describe what dishes you can make:
Are you able to follow instructions from a cookbook? Yes No
Do you enjoy baking? Yes No
How would you rate your housecleaning ability? Outstanding Above average Average Below average
Are you willing to perform light housekeeping duties such as: Tidying Vacuuming Mopping Laundry Washing dishes cleaning bathrooms
Do you know how to iron and hand wash clothing? Yes No
Do you know how to mend (simple hems etc.)? Yes No
Have you experience with gardening/plant care? Yes No
Name of Employer 1
Address of Employer 1
Email of Employer 1
Phone number of Employer 1
Dates of Employment Started: Left:
Will you use this employer as a reference? Yes No
Have you had problems with this employer? Yes No
If yes, please describe:
Detailed Job Description (Please list all tasks and duties that you completed in the home on a daily basis. Include children’s age(s) and gender, housekeeping duties, play activities, etc.):
Reason for leaving:
Name of Employer 2
Address of Employer 2
Email of Employer 2
Name of Employer
Address of Employer
Phone Number of Employer
Email of Employer
Do you need time off to attend religious services? If yes, when?:
What are your hobbies and interests?
What languages do you speak?
Do you smoke? Yes No
Do you drink? Yes No
Can you swim? Yes No
What activities do you enjoy?
What are your future goals?
What would you like potential employers to know about you? (This is your area to shine, to really give your future employers a window of whom you truly are. Please list information about
I agree to Preferred Personnel’s Code of Ethics Agree
I agree to provide Preferred Personnel with personal information which will be shared with potential employers in order to assist me in finding employment. Agree
Please Answer this Question.