Educator Initial Intake Form | Young Minds Family Dayhome Agency

Date

Educator Name

Program Name

Date of Birth

Address

Phone Number

Child Services or Legal Justice Involvement

If Yes, Provide Written Disclosure

Names & Ages of People Living in Your Home

Emergency Contact Information

Emergency Contact Name

Relationship

Phone Number

Address

Education & Certification

Education Background

Early Child Care Education Level

ECE Certification Number

Do You Have Pets?

Type of Pets

Professional Experience

Professional Work Experience (Start / End Date)

Home Information

Type of Housing

Own Your Home?

Secure Outdoor Space?

Medical Concerns / Conditions

Program Information

Program Start Date

Able To Transport Children?

Previously with Licensed Agency?

If Yes, Please Explain

Confirm Smoke Free Environment

Declaration

Educator Signature

Date