Nanny Application

Personal Information

First Name

Middle Name

Last Name

Home Address

Home Phone

Mobile Phone

Email Address

Date of Birth (MM/DD/YYYY)

Social Security Number

Are you free to remain and take up employment in the United States with no current immigration restrictions?

 yes no

Do you hold a full, valid driver’s license?

 yes no

You may be required to provide the items below. Please indicate which you have.

 3 or more child care references CPR-First Aid certification Child care certifications Photo Identification Passport Resume Letters of recommendation

Current Employment

Name of Employer

Address

Position Held

Start Date

End date

Ages of child(ren) at start date

Did the family have more children during your employment? List dates.

Brief description of duties

Reason for leaving

Compensation package

Previous Employment

Employer 1

Name of Employer

Address

Position Held

Start Date

End date

Ages of child(ren) at start date

Did the family have more children during your employment? List dates.

Brief description of duties

Reason for leaving

Compensation package

Employer 2

Name of Employer

Address

Position Held

Start Date

End date

Ages of child(ren) at start date

Did the family have more children during your employment? List dates.

Brief description of duties

Reason for leaving

Compensation package

Employer 3

Name of Employer

Address

Position Held

Start Date

End date

Ages of child(ren) at start date

Did the family have more children during your employment? List dates.

Brief description of duties

Reason for leaving

Compensation package

Employer 4

Name of Employer

Address

Position Held

Start Date

End date

Ages of child(ren) at start date

Did the family have more children during your employment? List dates.

Brief description of duties

Reason for leaving

Compensation package

Education

Qualifications obtained from Schools, Colleges and Universities. Please list highest qualification first

College or University

Area of Focus

Qualifications and grades obtained

High School

Area of Focus

Qualifications and grades obtained

Additional Training or Development

Include titles of programs and course dates.

Personal Statement

Abilities, skills, knowledge and experience. Please use this section to tell us about yourself. Please describe your interests or hobbies along with what type of personality you seek in a Family, and what you can contribute to that Family.

Criminal History

Have you ever been convicted of a felony?

 yes no

Have you ever been convicted of a misdemeanor?

 yes no

Do you have any criminal convictions?

 yes no

Have you ever been arrested?

 yes no

If yes to any of the above, please, including details and dates of offenses.

Health

Number of days sickness absence in the last 2 years

Do you have any health conditions that you would like to make us aware of?

Are you a smoker?

 yes no

Questionaire

Please answer the following questions. This will help us to determine the perfect fit for you.

Are you currently employed?

Ages you are comfortable with Infants, Toddlers, Pre-school, School-age?

How many children are you comfortable with?

What state is your driver’s license held in?

Have you been issued a driver’s license in any other states within the past 7 years? If “yes” which state?

Has your license ever been suspended? If yes, please explain.

Do you drive or take public transportation to work?

Are you willing to drive children?

If yes, in your own car or a family-provided car?

If you are willing to drive children in your car, please list the year, make and model of your vehicle.

Are you married, divorced, separated, engaged, single, student?

Who do you live with?

Are you looking for a position in which you can bring your child with you?

What languages are you fluent in?

Do you swim? If “yes” how well do you swim? Fair, Good, Excellent?

Are you comfortable working in a home with a pool?

Are you comfortable swimming with children?

Do you have any pet or food allergies? If “yes” please list.

Are you comfortable working in a home with pets?

Are you comfortable with a parent working from home?

Are you willing to do some housekeeping chores? If “Yes” please list.

Are you willing to help with cooking?

Are you willing and able to commit to at least one year to a nanny position? If “no” how long are you able to commit?

Details of Experience

Please describe your child care style.

Housekeeping experience.

Other related experience.

Do you have experience with multiples? Yes/No. If “yes” please describe.

Do you have experience with special needs? If “yes” please describe.

Thank you!