Mothers Information

  Contact (first & last name)     

  Last Name       First Name    

  Address      

  City                  State     Zip 

  Home Ph       Cell Ph

  Fax                     email

  Occupation     How long at this address?

  Bus. Name    

  Bus. Address

  Bus City               State     Zip

  Bus. Phone       Bus. Fax  

  

Fathers Information

 Last Name           First Name    

 Address 

 City                    State    Zip  

 Home Ph:          Cell Ph

 Fax                            Email   

 Occupation          How long at this address?

 Bus Name       

 Bus. Address  

 Bus City            State      Zip

 Bus. Phone           Bus Fax 

 

 Marital Status     Married    Separated     Divorced     Widowed    Single

 If separated or divorced, who has custody?

 What are visitation rights?                              

 Are there any other adults living with you?  

 If so, how many and their relation to you?

 Do you have a need to carry out any specific religious beliefs in your home? 

      

 What is the approximate square footage of your home? 

 Describe your family personality traits. 

   

 Do you have any pets? YesNo    (please describe)   

 How often do you travel and is it mandatory that the nanny stay overnight?

    

 

   (Personal References)

 (Please fill out two)

 Name            

 Address       

 City                   State   Zip

 Phone           

 Relationship 

 

 Name            

 Address       

 City                       State    Zip

 Phone            

 Relationship  

 

   (Children to be Cared For) 

      Name                                   Birth date                             Male/Female 

                        Male   Female

                        Male   Female

                        Male   Female

                        Male   Female

                        Male   Female

 

   (Specific Client Needs)  

Full    Part    On Call     Live out  Live in   Date needed

                          Describe times needed

Sun
Mon
Tue
Wed
Thr
Fri
Sat

  Any overtime?    Yes  No     If so explain.

 Will nanny do any transporting of children?    Yes No     If so, explain   

 

   Smoker    Nonsmoker    Smoker OK, if done outside

 Can Nanny bring her child?  Yes    No    (note: nanny may  charge less per hour)

    Nanny Duties  

   Pick children up from school            Yes    No

       If so, which days and time?

   Errands:                                             Yes     No

   Housekeeping                                   Yes     No

       If yes, please list

   Laundry                                               Yes     No

   Cooking                                              Yes     No

   Pet care                                              Yes     No

   Other   

 

   Please check any preferences you have in your child/children's Nanny and indicate if mandatory.

   Education background in childcare development:        Preference    Mandatory

   CPR certification                                                               Preference    Mandatory

   First Aid certification                                                         Preference    Mandatory

        (if first aid mandatory, this will be at employer's expense)

 

   Please describe the personality trait of a Nanny you would employ:

   (i.e., loving, calm, responsible, strict, etc.) 

   

   

    Any Comments?

   

 

    (Salary) 

   What is the approximate hourly salary you expect to pay a Nanny?

   If overtime, how will you compensate the Nanny?

   Any benefits? (i.e., vacation, holiday, sick time, insurance)

   

 

       (Miscellaneous)

   How did you hear about Nannies Who Care?   Nannies Who Care (web site) Searched the internet Citrus Park newspaper Referral Received brochure in mail Community website Doctor's office

   Your assistance in filling out this application in full is greatly appreciated.  Thank you for the opportunity of allowing us to serve you.