Parent #1

Does Your Work Require You To Travel? YesNo

If Yes, Please Explain

Do You Ever Work At Home?* YesNo

If Yes, Please Explain

Parent #2

Does Your Work Require You To Travel? YesNo

If Yes, Please Explain

Do You Ever Work At Home? YesNo

If Yes, Please Explain

Child #1

MaleFemale

Age:

Allergies: YesNo

If Yes, Please Explain

Days in School:

Child #2

MaleFemale

Age:

Allergies: YesNo

If Yes, Please Explain

Days in School:

Child #3

MaleFemale

Age:

Allergies: YesNo

If Yes, Please Explain

Days in School:

Child #4

MaleFemale

Age:

Allergies: YesNo

If Yes, Please Explain

Days in School:

Do Any of Your Children Require Special Needs, Such as Health, Behavior, Emotional, or Academic Concerns? If Yes, Please Explain.

Do Other Adults Live in Your Home?: YesNo

If Yes, Whom?

Do You Have Any Pets? YesNo

If Yes, What Type?

Will the Nanny be Require to Care for the Pet? YesNo

If Yes, Please List the Duties the Nanny Would Need to Perform.

Family Activities and Interests

How Many Times Per Year Do You Go On Vacation?

What Type of Parent Are You? Easy GoingLenientNervousStrict

Please Explain Your Family Method of Discipline

Family House Rules

Does Anyone in Your Home Smoke? YesNo

Applying For: Full-TimePart-TimeSummer/Temporary

Hours and Days Needed:

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

WeeklyHourly

Please Indicate Benefits You Will Provide the Nanny: Health InsuranceGas ReimbursementFamily Vehicle

Please List Number of Paid Vacation Days:

We recommend 2 weeks of paid vacation, not including paid holidays.

Please Indicate Paid Holidays: New Year's DayMemorial DayFourth of JulyLabor DayThanksgiving DayChristmas EveChristmas Day

Will You be Withholding Social Security, Medicare, and Taxes From Your Nanny’s Earnings or Will That Be Left Up To The Nanny?

YesNo(By law you are required to pay only social security, unemployment, and Medicare.)

Qualities Important to You in a Nanny

Is Driving Required by the Nanny? YesNo

If Yes, Please Describe

Is There a Car Available for the Nanny to Drive? YesNo

If Yes, Please Describe Authorized Uses

Is Travel Required by the Nanny? YesNo

Please Describe Any Cooking Expected of the Nanny

Please Describe Any Cleaning Expected of the Nanny

Is There a House Cleaner in Addition to the Nanny? YesNo

If Yes, What Frequency?

Have You Ever Employed an In-Home Child Care Provider? YesNo

If Yes, Please Describe What Type and How Long?

What Did You Like, or Dislike, About the Person or Experience?

Please List Three References or Nannies That Know Your Family Well. Please Do Not Include Relatives

To ensure the safety of the nanny as well as the family, Iowa Elite Nannies makes it a policy to check all references supplied. We guarantee that all information attained from the reference and background check process will only be used as part of the nanny selection and engagement process and kept strictly confidential.

Describe, in Detail, the Nanny’s Responsibilities With Your Children

Describe, in Detail, the Nanny’s Housekeeping Responsibilities

How Did You Hear About Midwest Elite Nannies?

Statement of Truth for Application:*By submitting this application, I hereby state that there are no criminal acts being conducted in our home. We certify that our home is free of drug or alcohol abuse by any member of the family. We declare that there has not been any incidents of domestic violence in our family home that have been reported to the police. We also have the financial ability to pay the hourly rate and benefits as discussed with Midwest Elite Nannies to the nanny on a timely basis. I hereby certify that the information we have provided above is true and correct.