Family day carer

Full name

Date of birth

Address

Suburb

Postcode

Email

How did you hear about us?

Reason for making application to be a care provider

*Previous employment

Including experience with children.

When are you available to care for children

Please include days and times.

Times

Language spoken at home

Other languages spoken

Do you have permanent residency status in Australia?

Yes

No

*Referees

Plaese provide the name and address details for two referees (not family members).

Partner's name

Date of birth

Partner's occupation

Child's name

Date of birth

Child's name

Date of birth

Any other occupant in your home

Date of birth

Relationship to you

Second other occupant

Date of birth

Relationship to you

Is your premises rented?

Yes

No

Do you live in a

If your home is highset, are you prepared to childproof your home?

Yes

No

Do you have a fenced outdoor area?

Yes

No

Do you have a swimming pool?

Yes

No

Is it Council approved?

Yes

No

Does the pool fence meet Australian Safety Standards?

Yes

No

Do you own domestic animals?

Yes

No

Do aspects of your house hinder you providing a safe environment for children?

Please provide details.

Do you have any objections to a criminal history check?

Yes

No

If accepted, how long will you commit to family day care?

I am willing to abide by the decisions of the coordinators in matters relating to my becoming a child care provider with Wesley Mission Brisbane schemes

Yes

No

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