First Name: Last Name:

Date of Birth: Marital Status: Single Married Divorced Widowed

Spouse/Partner's First Name: Spouse/Partner's Last Name:

Spouse/Partner's Date of Birth:

Address:

City: State: ZIP:

Home Phone Number: Work Phone Number:

Cell Phone Number: Spouse/Partner's Phone Number:

How did you hear about us? Website TV Radio Friend/Family GCTFS employee Social Services (DSS) Word of Mouth Other

How many people live in your home? How many are adults? How many are children?

What are the ages of the children in your home?

How many of them are male? How many of them are female? How many bedrooms are in your home?

Are you presently employed? Yes No Place of Employment:

Is your spouse/partner presently employed? Yes No Place of Employment:

What is your estimated income? Do you receive federal assistance/food stamps/welfare aid? Yes No

What medical/child care work experience do you have? Please explain:

What is the highest level of education you completed? Some High School Graduated from High School Some College Graduated from College Master's Degree or higher

What is the highest level of education your spouse/partner completed? Some High School Graduated from High School Some College Graduated from College Master's Degree or higher

Would you consent to a criminal background check? Yes No

Have you or your spouse ever been arrested? Yes No

If you or your spouse have been arrested, were you or your spouse/partner convicted of a felony? Yes No

If you aswered yes, please explain:

Would you and your spouse/partner agree to get a physical examination? Yes No

If you aswered no, please explain:

What age range child are you willing to have in your home? Male Female

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