For office use only: Date/Time to Meet: Place to meet: Reference 1__Reference 2__ Background check status: Thank

you for your interest in watching our son as his babysitter. In order to be a candidate you must: 1. Be at least 18 years of age 2. Have no criminal background 3. Have a current Drivers License and be able to provide your own transportation 4. Have experience with children 5. Be a non-smoker 6. Be able to provide 2-4 references (no relatives) 7. Be CPR certified or willing to get certified within 45 days of becoming a sitter full time (Red Cross, YMCA, etc) 8. Responsible and flexible to meet the job requirments 9. Treat our child as if he was your own Please note: All sitters are to come to our house and not leave with the child. Other children are not allowed to accompany you to jobs under any circumstance. If you meet all of the criteria, feel free to proceed with the application!

Last updated 9/20/2012

Date: Are you available to attend work within 24 hour notice? Are you interested in coming on full-time or very full-part time if the opportunity arises? Personal Information

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Full Name (middle initial): ____________________________________________________________________ Current Mailing Address: _____________________________________________________________________ E-mail Address: ____________________________________________________________________________ Cell Number: ______________________________________________________________________________ Birthday: __________________ Current Drivers License #: ___________________________________________________________________ Make/model/year of your car: _________________________________________________________________ Do you have car insurance? __________________________________________________________________ Background Information Please answer the following with "yes" or "no". Have you ever participated in, been accused or convicted of, or pleaded guilty to abuse or any sexual misconduct? Have you ever been convicted of or pleaded guilty to any criminal offense of any kind? Are you aware of any traits or tendencies that you possess that could pose any threat to children? Are you using illegal drugs? Have you ever gone through treatment for alcohol or drug abuse? If so when? Is there anything in your life (past or present) that may affect your ability to provide a safe environment for children? If the answer is "yes" to any of these questions, please explain. Additional Information you would like to share:

Last updated 9/20/2012

Please list two to four references First/Last Name of Family Relationship to you Ages of Children Phone Number E-mail Address

APPLICANTS STATEMENT I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statement contained in the application for employment as may be necessary in arriving at an employment decision. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with our family is of an at will nature, which means that we may discharge an employee at any time with or without a reason. In the event of employment, I understood that false or misleading information given in my application or interview(s) may result in discharge. I understood, also, that I am required to abide by all rules and regulations of the employe which will be presented upon hire. Signature of Applicant: _______________________________________________ Date:________________

Last updated 9/20/2012