Are You Comfortable Transporting Children in a Vehicle? YesNo

Do You Require a Vehicle to be Provided? YesNo

Do You Own a Vehicle? YesNo

If Yes, Enter Make and Model:

Are You Open to Using Your Car for Travel With the Kids? YesNo

Do You Have Insurance? YesNo

Job Preferences

Please Check Your Preferences: Live-InLive-OutFull-TimePart-TimeSummer/TemporaryWeekends

Are You Flexible on Days and Hours? Very FlexibleSomewhat FlexibleNot Flexible

How Long Do You Want to Work in This Position? 6 Months1 Year2 Years3+ Years

Type of Job Applying For: SitterNannyNanny/HousekeeperNanny/Household Manager

Please Select the Weekly Duties You Are Willing to Do: Light HousekeepingHeavy HousekeepingChildrens' LaundryGrocery ShoppingMeal PlanningCooking for Kids or FamilyDrivingNeighborhood Carpool to Activities/SchoolErrandsDoctor Appointments

Are You Willing to Travel With the Family?* YesNo

Do You Smoke?* YesNo

Do You Drink Alcohol?* YesNoOccasionally

Pets

Is Working in a Home With Pets Okay? YesNo

Are You Allergic to Dogs? YesNo

Are You Allergic to Cats? YesNo

Are You Willing To (Check All That Apply): Care For the Family PetVet AppointmentsWalks

Education

Did You Graduate?* YesNo

Hobbies and Interests

Medical and Mental Health Information

In order to assure safe child care we must know about medical and psychiatric conditions that could affect your ability to perform the job.

Are You Presently Suffering From Any Communicable Diseases That Could Be Transmitted to a Child You Are Caring For?* YesNo

Are You Presently Taking Any Medications, Prescribed or Not, That Affect Your Judgement, Coordination, Levels of Alertness, and Ability to Respond in an Emergency?* YesNo

Do You Have Any Physical Condition That Might Impair or Prevent Your Ability to Perform Any Reasonably Physical Act Normally Required in the Care or Protection of Children?* YesNo

First Aid and CPR

Do You Have a Current CPR Certification?* YesNo

Do You Have a Current First Aid Certification?* YesNo

Can You Swim?* YesNo

Are You a Certified LifeGuard? YesNo

Child Care

Do You Have Experience Working For Families of Mulitiples? YesNo

Would You Care for Twins? YesNo

Would You Work With Children With Special Needs? YesNo

Please Indicate the Type of Family Situation You Would Like to Work In: Parents Working Outside the HomeAt-Home Parent

Previous Nanny Experience
List previous employers with the most recent first.

EMPLOYER 1

Please Select One:* GrossNetPer HourPer Week

Type of Position:* Live-InLive-OutFull-TimePart-Time

Responsibilities (Check All That Apply)*: Light HousekeepingHeavy HousekeepingCookingDriving KidsErrandsHomeworkDoctor AppointmentsSwimming LessonsOther

EMPLOYER 2

Please Select One: GrossNetPer HourPer Week

Type of Position: Live-InLive-OutFull-TimePart-Time

Responsibilities (Check All That Apply): Light HousekeepingHeavy HousekeepingCookingDriving KidsErrandsHomeworkDoctor AppointmentsSwimming LessonsOther

EMPLOYER 3

Please Select One: GrossNetPer HourPer Week

Type of Position: Live-InLive-OutFull-TimePart-Time

Responsibilities (Check All That Apply): Light HousekeepingHeavy HousekeepingCookingDriving KidsErrandsHomeworkDoctor AppointmentsSwimming LessonsOther

OTHER EMPLOYMENT

Please Take Time to Answer How You Would Handle the Following Situations:

Please List Three Personal References. Do Not Include Relatives.

Emergency Contact Information

Certification of Application:By submitting this form, I hereby certify that the information contained herein is true and correct to the best of my knowledge.*