Child Care Worker Intake Form

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This form is intended to provide families of essential personnel in our community with a list of potential child care providers. Decisions on hiring and potential payment for services will be negotiated between the provider and the family in need. Families will be responsible for and encouraged to complete background checks on those providing services.
We would also encourage providers to complete background checks on potential employers. The following links can be use for both purposes.
a. National Sex Offender Registry Site: https://www.nsopw.gov/
b. Iowa Department of Criminal Investigations Background Check Site: https://dps.iowa.gov/divisions/criminal-investigation/criminal-history/record-check-forms
c. Iowa Courts Online: https://www.iowacourts.state.ia.us/ESAWebApp/DefaultFrame

**If you are a minor (under 18) you must have a parent or legal guardian fill this form out with you.

Last Name *

First Name *

Birthdate (mm/dd/yyyy) *

Phone number

Preference in contact *

Phone

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