Peanut Butter Pals Daycare Association
		Please print this form, have three references who are knowledgeable with your work complete the forms, and submit the completed forms with your resume.
		Childcare Reference Form How long have you know the individual, and in what capacity? Does this person show any physical, mental, or substance abuse problems that might affect his or her ability to care for children? If yes, explain. Does this person show warmth, love and acceptance of children? Please provide examples. Do you think this person would provide good childcare? Please explain why. Would you leave a child in this person?s care? To your knowledge, has this person ever abused or neglected a child or dependent adult, and is there anything about this person that you would consider dangerous to a child? If yes, please explain. How does this person deal with stress? Other comments: (use additional pages is needed) _____________________________________________________________________________ Printed Name Address Phone Number ______________________________________________________________________________ Signature Date