Your Name (required)
Street Address (required)
Home Phone (required)
Your Email (required)
Are you 18 year of age or older? (required) YesNo
Select all that apply. To select multiple entries click + command/CTRL.
—Please choose an option—Child/Human DevelopmentChild PsychologyNursingSpecial EducationElementary EducationTherapeutic Rec.Early Childhood EducationSpeech & LanguageSocial Work
Other Courses Training:
—Please choose an option—Typically developing childrenChildren with special needsPhysical ImpairmentsHearing ImpairmentsDevelopmental DelaysAutismCerebral PalsyBehavior disordersSeizure disordersMedially fragile Children
Other languages that you speak (including sign):
How did you hear about this program?
Personal care for all ages (including diapers)
Any weight-lifting restrictions?
Have you been convicted of, or under pending charge(s) or indictments(s) (felony or misdemeanor) wither within or outside the Commonwealth of Virginia?
Are you a parent currently receiving respite services? YesNo
Are you certified in CPR/First Aid (including infant/child CPR)? YesNo
Enter number of years of experience for each item below.
Children with autism
Children with speech and language delays
Children with behavior problems or behavior disorders
Medically fragile children
Select all that you are willing to serve.To select multiple entries click + command/CTRL.
—Please choose an option—ChesapeakeVirginia BeachNorfolkSuffolkPortsmouthFranklinHamptonNewport NewsWilliamsburg
Are you currently open for respite childcare referrals? YesNo
How many hours per month are you available to provide respite care?
Please list all the hours and days that you are available to provide respite care services:
Please submit up to three professional references with their phone number so we may contact them.
Please upload your resume and cover letter using the upload fields below.
Although you may see a spinning arrow for a while, your application will be received you should receive a confirmation email within a few minutes.