TeacherCare Family | TeacherCare

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Family Application

Have you registered with us in the past?

No Yes

We require the following types of employment

check all that apply Select all / None

In what geographical area would you require service?*

Parent

Parent's Name*

Occupation

Employer

Work/Cell Phone

Email*

Parent

Parent's Name

Occupation

Employer

Work/Cell Phone

Home

Home Phone

Address

City*

State*

Zip Code*

How many children do you have?

Child 1

Name

Date of Birth

Optional: profile of my child

No Yes

My child is comfortable with new people.

Usually Sometimes

My child enjoys going on outings.

Usually Sometimes

My child enjoys cuddling.

Usually Sometimes

Emotional Development
I would like my child to

Select all / None

Physical Development
I would like my child to

Select all / None

Cognitive Development
I would like my child to

Select all / None

Language & Literacy Development
I would like my child to

Select all / None

Social Development
I would like my child to

Select all / None

My child does not enjoy

My child's favorite activies are

By nature, my child is usually

My child's regular routines include

Is there anything else your teacher should know about your child?

Child 2

Name

Date of Birth

Optional: profile of my child

No Yes

My child is comfortable with new people.

Usually Sometimes

My child enjoys going on outings.

Usually Sometimes

My child enjoys cuddling.

Usually Sometimes

Emotional Development
I would like my child to

Select all / None

Physical Development
I would like my child to

Select all / None

Cognitive Development
I would like my child to

Select all / None

Language & Literacy Development
I would like my child to

Select all / None

Social Development
I would like my child to

Select all / None

My child does not enjoy

My child's favorite activies are

By nature, my child is usually

My child's regular routines include

Is there anything else your teacher should know about your child?

Child 3

Name

Date of Birth

Optional: profile of my child

No Yes

My child is comfortable with new people.

Usually Sometimes

My child enjoys going on outings.

Usually Sometimes

My child enjoys cuddling.

Usually Sometimes

Emotional Development
I would like my child to

Select all / None

Physical Development
I would like my child to

Select all / None

Cognitive Development
I would like my child to

Select all / None

Language & Literacy Development
I would like my child to

Select all / None

Social Development
I would like my child to

Select all / None

My child does not enjoy

My child's favorite activies are

By nature, my child is usually

My child's regular routines include

Is there anything else your teacher should know about your child?

Child 4

Name

Date of Birth

Optional: profile of my child

No Yes

My child is comfortable with new people.

Usually Sometimes

My child enjoys going on outings.

Usually Sometimes

My child enjoys cuddling.

Usually Sometimes

Emotional Development
I would like my child to

Select all / None

Physical Development
I would like my child to

Select all / None

Cognitive Development
I would like my child to

Select all / None

Language & Literacy Development
I would like my child to

Select all / None

Social Development
I would like my child to

Select all / None

My child does not enjoy

My child's favorite activies are

By nature, my child is usually

My child's regular routines include

Is there anything else your teacher should know about your child?

Child 5

Name

Date of Birth

Optional: profile of my child

No Yes

My child is comfortable with new people.

Usually Sometimes

My child enjoys going on outings.

Usually Sometimes

My child enjoys cuddling.

Usually Sometimes

Emotional Development
I would like my child to

Select all / None

Physical Development
I would like my child to

Select all / None

Cognitive Development
I would like my child to

Select all / None

Language & Literacy Development
I would like my child to

Select all / None

Social Development
I would like my child to

Select all / None

My child does not enjoy

My child's favorite activies are

By nature, my child is usually

My child's regular routines include

Is there anything else your teacher should know about your child?

Concerns, Needs & Interests

Schedule

Start TimeEnd Time

Days Required (choose a start and end time for each day that applies)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Earliest Start Date:

Latest Start Date:

Other (please specify)

For Childcare Only

Must the teacher drive?

No Yes

Have a car?

No Yes

Would you consider hiring a teacher who wishes to bring her child?

No Yes

I want my teacher to provide:
Developmental requirements

Select all / None

Custodial requirements

Select all / None

Other requirements

Family Application

Parent

Parent

Home

Child 1

Child 2

Child 3

Child 4

Child 5

Schedule

Start TimeEnd Time

For Childcare Only

Miscellaneous