Child Care Registration Form - Child Care Professionals

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Family Name
____________________________
Home Phone
____________________________
Cell Phone
___________________________
Preferred Phone ____________________________
E-mail address
____________________________
Referral Source ____________________________
Date
____________________________
CHILD CARE REGISTRATION FORM
Positions: FT___(Live in___ Live Out___)
PT (ongoing)___
and/or Occasional/Temp.___
A non- refundable $100.00 registration fee will be processed upon receipt of the registration form. The fee
includes registration with The Occasional/ Temporary Service for one year. Credit card information is
required in order to use Occasional/ Temporary and Full-time Services through Child Care Professionals,
Inc.
(Please print clearly)
Credit Card:
Master Card ___ Visa ___
Name on card:
____________________________
Card number:
____________________________
Expiration date: ____________________________
Billing address: ____________________________
____________________________
Family Information
Name________________________ Office Phone__________________ Office Fax__________________
Occupation ___________________ Company__________________
(Wife)
Name________________________ Office Phone__________________ Office Fax__________________
Occupation___________________ Company __________________
(Husband)
Home Address__________________________________City/State/Zip Code_______________________
Cross Street_______________Driving Directions______________________________________________
______________________________________________________________ Locality_________________
Special/ Behavioral Needs
Children:
Name_________________DOB_____________M___ F___ _____________________
Name_________________DOB_____________M___ F___ _____________________
Name_________________DOB_____________M___ F___ _____________________
Do you have domestic help? Yes ___ No ___ Do you have pets? Yes ___ No ___ Describe____________
Does either parent work from a home office? Yes__ No__ If yes, what percentage of time/wk.? _________
Would you consider a provider that has a young child of their own Yes___ No___ May Consider________
Position Description
Starting Date:_______________
Ending Date:_______________
Days/Wk.:
M
T
W
Th
Fri.
Sat.
Sun.
Hours:
_____-_____/_____-_____/_____-_____/_____-_____/_____-_____/_____-_____/_______
Expectations of child care provider:_________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Automobile Required: Yes ___ No ___
Non Smoker required: Yes ___ No ___
Education requirement: High school graduate___ Some college___ College grad___ No preference___
Wage Range (based on 40-50 hrs./wk. Or hourly):________per________Health benefits avail for FT_____
All information is accurate without omissions of any kind. I understand the placement agreement and my
responsibilities with Child Care Professionals, Inc.
Signature:______________________________________________Date:__________________
Child Care Professionals, Inc.
Phone:
(513) 561-4810
Fax Registration and Placement Agreement Forms to: (513) 272-1714 or email to:

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