* required fields

 Full Name  *

 Last name    *       Middle     

 First name   *       Maiden

 Address

 City                 State   Zip

 Describe approximate location of address 

 How long at this address?

 Phone     Cell# Email  *

 Previous address

 Previous city           State Zip

 How long at this address

 Soc Sec.    Drivers Lic 

 Marital Status ( Married   Separated   Divorced   Widowed   Single)

 Do you have any children?

 Race: (Necessary for criminal check) Caucasian Hispanic Black Asian Native Indian   Us Citizen? Yes No

 Birth date

 How did you hear about Nannies Who Care?  Newspaper Searched Internet with keywords Yellow pages Referral Doctor's office Saw an advertisement

 Previous Employment for the Last 5 Years

 (These should include childcare references first, then other employment)

 ** Remember - you must have full address (zip & phone) We prefer fax numbers!

 Name of employer/company * Job title *

 Employers address *

 Employers city          *  State *    Zip  *

 Employers phone     *    Fax * (From/To)*

 Employers email     

 Full/Part Time? Full  Part       Salary   *

 Reason for leaving                 *

 State the ages of children at start of employment *

Name of employer/company Job title

 Employers address

 Employers city          State   Zip 

 Employers phone     Fax (From/To)

 Employers email      

 Full/Part Time? Full  Part       Salary   

 Reason for leaving

 State the ages of children at start of employment

Name of employer/company Job title

 Employers address

 Employers city          State   Zip 

 Employers phone     Fax (From/To)

 Employers email     

 Full/Part Time? Full  Part       Salary   

 Reason for leaving

 State the ages of children at start of employment

 IF FROM OUT OF STATE OR COUNTRY, LIST THE STATES/COUNTRIES PREVIOUSLY LIVED AND THE DATES IN THAT STATE/COUNTRY

 1.

 2.

 3.

 EDUCATION

                         Name and address            Yrs Attended             Major                  Degree

    High School     4 years 3 years 2 years 1 year None         Diploma None Other

    College            4 years 3 years 2 years 1 year None         BS or BA degree None AA or AS degree Still attending

  QUALIFICATIONS 

  CPR certification?     

  First Aid certification 

  Can you swim?                                  YesNo                          

  Own transportation?                         YesNo

  Can transport children in your car?         

  Smoker?                                            Yes No

  Bilingual ?                                          Yes No

  MEDICAL

  Have any contagious diseases?                                          Yes No

  Do you suffer from epilepsy, convulsions or dizzy spells? Yes No

  Do you suffer from any mental illness?                                 Yes No

  Any current or previous drug or alcohol problem?              Yes No

  Are you currently taking any medication?                           

  If so, please explain what type, why you must take the medication, and any side effects caused from the medication.

  Name of Physician

                 Address  

                 City             State      Zip 

   GENERAL

  Live in or out?  In Out Either        Full-time   Part-time   On-call  

  Can you work overnight? Yes  No     Can you work nights & weekends? Yes No

  Can you work overtime?

  Areas you wish to work in North Tampa Central Tampa South Tampa Brandon/Riverview Bradenton Sarasota Port Charlotte Ft Myers Naples Orlando Lakeland Melbourne Titusville Cocoa Beach New Port Richey Palm Harbor Clearwater St Petersburg Venice (Hold Ctrl key down for multiple locations)

  Housekeeping other than what is needed to clean after children?(If so, explain):

  Preference to how many children and ages? (If so, explain)

  Pets okay?:

  Travel with family okay?            Yes No     Can you take children on field trips? Yes No

  Have you ever been arrested? Yes No

  Days of week Avail       Hours Avail

  Sun                       

  Mon                  

  Tue                   

  Wed                 

  Thr                    

  Fri                     

  Sat                       

    Total hours/week you wish to work

  What is the salary range you expect to receive? 

  Are you currently on file with another agency or referral service?    

  PERSONAL REFERENCES   (These should be different from employment references, also OTHER THAN FAMILY)

  Name            *

  Address        *

  City                * State *  Zip *

  Phone              *  Fax   

  Email            

  Relationship  *

  Name           

  Address       

  City                State   Zip

  Phone                Fax  

  Email            

  Relationship

  Name           

  Address       

  City                State   Zip

  Phone                 Fax 

  Email            

  Relationship

  Please describe any conditions of employer, household, children, etc., which you feel important.  This will enable us to find the best suitable position for you.

  *

Please note: If you have any error messages when submitting this application then use the back arrow to come back to this screen to make sure you can print a hard copy.  Call Nannies Who Care for assistance.

       (Right click & print for your own hard copy)