KCMS Childcare Referral: Babysitter Form

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Please complete this form if you are able to provide childcare.

Thank you for helping to provide childcare to our healthcare providers in this time of crisis.

First Name *

Last Name *

Phone Number *

Email Address *

Are you 18 years or older? *

Yes

Are you CPR or First Aid certified? *

CPR

First Aid

Neither

Required

What has been your experience working with children? *

Babysitting/nannying

After school childcare program

Youth recreational program/summer camp

Licensed childcare center

I am a parent

Other:

Required

What age range(s) are you able to care for? *

Infant (12 months and under)

Toddler/ Preschool

School age (5 and up)

Required

Are you able to care for children who have special needs? *

Yes

Other:

Do you speak any languages other than English? If so, please list them below.

Do you have a car or a form of personal transportation? *

Yes

Other:

Home zip code in Seattle *

Please indicate your availability to provide childcare. Check all that apply. *

Morning: 6AM - 12PM

Afternoon: 12PM - 6PM

Evening: 6PM - 12AM

Overnight: 12AM - 6AM

Unavailable all day

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

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