In home carer

*Full name

Address

Suburb

Postcode

Home phone

Mobile

Email

Date of birth

Country of birth

Languages spoken

Do you have permanent residency status in Australia?

Yes

No

Do you have a visa to work in Australia?

Yes

No

Current occupation

Employment history

Please give a brief summary of your work history, including experience with children and any relevant qualificiations / training.

Availability

Please indicate your availabiltiy to provide In Home Care.

Time availability

Please state the time of day you are available for example, day, night, overnight care.

What hours are you prepared to work each day?

Is there an age group of children you would not be comfortable caring for?

Yes

No

If yes, please provide details.

Details

Are you willing to care for children from different cultural backgrounds?

Yes

No

Are you willing to care for chidren when they are sick or recuperating from an illness?

Yes

No

Would you feel comfortable caring for a child suffering from a common childhood infection?

Yes

No

Eg measles, mumps and chickenpox.

Would you be willing to care for chidren with additional needs?

Yes

No

Do you have any skills or experience caring for children with disability?

Yes

No

If yes, please give details.

Details

Do you have a current driver's licence?

Yes

No

Driver's licence number

Are you prepared to transport chidlren if required?

Yes

No

Do you have a vehicle in road worthy condition?

Yes

No

Are you prepared to maintain a smoke free environment whilst offering in home care?

Yes

No

Referees

Please provide names,addresses and phone numbers for two professional referees (not family members) who have seen you working in a child caring capacity.

Are you prepared to attend an interview and inducation training?

Yes

No

I certifiy the above information is correct

Yes

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