Community District (if known)

How did you hear about St. Dominic’s?

How many children can you care for?

Which sex?   Male Female Both 

What age range can you care for? (please give a 5 year range)

Are you employed?  Yes  No

If yes, Employer Name:

Position Held:

Work Schedule:

Work Number:

Work Address:

If employed, who will be the caretaker for the children
during your work hours?


Other Household Members

Name:

Sex: Male Female

Age:

Relationship:

Name:

Sex: Male Female

Age:

Relationship:

Name:

Sex: Male Female

Age:

Relationship:

Name:

Sex: Male Female

Age:

Relationship:

How many bedrooms do you have?

What are the sleeping arrangements?

Other Comments: