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702 N Carrollton Ave
New Orleans, LA

504-486-5044
help@dependablecare.net

Mon - Fri 8:30am - 4:30pm
24/7 Coordinators Available

Child Care Application

We require at least TWO years of experience as a child caregiver. Some examples of child care experience: a private home as a babysitter or nanny on a consistent basis, employment in a daycare center, preschool, or elementary school, etc. Should your application be approved, Dependable Kid Care (DKC) will conduct employment verifications.

You may complete this online below, or download this form as a printable PDF.

 


Applicant Information
Name: Last First M.I.
Mailing Address: Apt.: D.O.B.:
City: State: Zip:
Phone:
Email:
Additional Contact #:
Social Security No.:
Have you ever been on this registry before?  Yes No If yes, when?
Have you ever been convicted of a felony, other than a traffic violation?  Yes No If yes, explain:
Education
High School: Address:
From: to Did you graduate?:  Yes No Diploma:
College: Address:
From: to Did you graduate?:  Yes No Diploma:
Other: Address:
From: to Did you graduate?:  Yes No Diploma:
History
Do you have any physical limitations that will prevent you from performing daily tasks?:  Yes No
If yes, please explain:
Do you smoke?  Yes No
Do you own a vehicle?  Yes No Is the vehicle a:
Do you have car insurance? (Proof of insurance required) Yes No
Are you available:  Full-time Part-time Occasionally Are you available:  Mon-Fri Sat & Sun Holidays
Please check any of the following shots/immunizations that you have received? Pertussis (aka Whooping cough) TB test Hepatitis B Tetanus Influenza (Flu)
Emergency Contact
Name: Phone #:
Relationship to you: Email:
References

Please list three professional references (e.g. a current or previous supervisor).

Name: Phone #:
Professional Relationship: Email:
Name: Phone #:
Professional Relationship: Email:
Name: Phone #:
Professional Relationship: Email:
Previous Employment
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary Ending Salary
Responsibilties:
From: To: Reason for Leaving:
May we contact your previous supervisor for a reference?  Yes No

Company: Phone:
Address: Supervisor:
Job Title: Starting Salary Ending Salary
Responsibilties:
From: To: Reason for Leaving:
May we contact your previous supervisor for a reference?  Yes No

Company: Phone:
Address: Supervisor:
Job Title: Starting Salary Ending Salary
Responsibilties:
From: To: Reason for Leaving:
May we contact your previous supervisor for a reference?  Yes No

I certify that all information given herein is true and correct to the best of my knowledge. I authorize any investigation of all statements and information contained in this application for referral which is necessary to be considered for referrals through the DKC registry. I understand that I may be immediately dismissed without further obligation from the client I have been referred to. I also understand that Dependable Nursing & Family Care, Inc. (dba Dependable Kid Care) acts as a facilitator in my placement. I agree to hold DNFC, Inc. harmless and to indemnify DNCF, Inc. for and from any and all claims, including attorney fees and court costs made by any person related to my placement.

If this application leads to my acceptance on the registry, I understand that false or misleading information in my application may result in my immediate release from the registry and future eligibility.

DNFC, Inc. reserves the right to refuse any applicant for placement.

Signature of Applicant: (Initials)