Head Start Family Child Care Contract Services Application
Date of Application
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please indicate the location you are applying for:
My Home
Other
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Employment History
Start with your most recent, including self-employment
Employer #1
Employer Name
Employer #1 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer #1 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Employer #1 Dates Employed
Summarize Responsibilities
Employer #2
Employer Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Dates Employed
Summarize Responsibilities
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Educational Background
High School
Number of Years Completed
College/University
Number of Years Completed
Major
Degree
Graduate School
Number of Years Completed
Major
Degree
Other Professional Training
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Skills & Qualifications
Summarize any special training, skills, licenses, certifications, and/or characteristics of yourself that are appropriate to childcare or the education field.
List any professional, trade, business, or civic associations and any offices held. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability, or other protected status.)
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Are you willing to attend class to acquire a CDA or related course work?
Yes
No
Will you travel if required? (Ex: To attend CDA training conferences)
Yes
No
Will you work evening hours?
Yes
No
Do you currently have a licensed family childcare?
Yes
No
Is your childcare licensed by the State of Minnesota?
Yes
No
How many children are you licensed for?
How many children currently attend your childcare?
List the ages of the children currently attending your childcare.
Do you have a second adult caregiver or co-licenser?
Yes
No
Do you have a reliable substitute?
Yes
No
Are you willing to obtain required childcare liability insurance?
Yes
No
Briefly describe activities you are providing for children in your care and your daily schedule.
What are the most important things a childcare provider can do for the children she/he cares for?
How often do you read to children?
How often do you go outdoors?
How much time is spent daily watching television?
List any additional information you would like considered.
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References
Please list 3 references
Reference #1
Reference #1 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference #2
Reference #2 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference #3
Reference #3 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
For more information, contact:
Darcy Fritze, Phone: (218) 732-7204 Email: dfritze@mahube.org
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