| Name |
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| Email Address |
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| Street Address |
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| City, State, Zip Code |
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| Home Phone |
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| Work Phone |
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| Cell Phone |
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| Date of Birth |
(mm/dd/yy) |
| Driver's License State & Number: |
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| Name, Address & Phone Number of emergency contact (state relationship) |
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| When is the best time to reach you? |
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| When can you begin working? |
(mm/dd/yy) |
| Position(s) applying for: |
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| If you are applying for a part-time nanny position, how many hours? |
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| What length of employment are you seeking? |
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| What days/hours are you available to work? |
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| Are you available to work some nights/weekends? |
Yes No
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| Geographic area(s) desired: |
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| Number of children willing to care for: |
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| Ages of children preferred: |
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| Experience with what ages? |
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| Can you legally accept employment in the US? |
Yes No
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| Have you ever been convicted of misdeameanor or felony? |
Yes No |
| If yes, please explain: |
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| Do you smoke? |
Yes No |
| Do you have a valid driver license? |
Yes No |
| When was your last ticket or accident? |
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| Please explain: |
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| Has your license ever been suspended? |
Yes No |
| Have you ever been charged and/or convicted of a DUI or DWI? |
Yes No |
| Do you own a car? |
Yes No |
| If yes, year, make and model: |
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| Name of insurance company: |
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| Do you swim? |
Yes No |
| Are you CPR certified? |
Yes No |
| Are you First Aid certified? |
Yes No |
| Highest level of eduction: |
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| What college did you attend? |
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| What was your degree? |
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| If you are relocating, why did you choose this area? |
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| Does your family support your relocating? |
Yes No |
| What are you looking for in terms of salary? |
$ |
| What were you paid in your last job? |
$ |
| What other languages do you speak? |
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| Describe your health status: |
Excellent Good Fair Poor |
| Any allergies or health limitations? |
Yes No |
| If yes, please explain: |
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| Are your immunizations up to date? |
Yes No |
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Please be as open and complete as you can for the following questions as they will help us find the right family for you: |
| Why do you want to be a nanny? |
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Please describe your experience with three families that you have provided childcare for. |
| Name of Family #1: |
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| Street address: |
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| City: |
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| State: |
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| Zip code: |
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| Home Phone: |
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| Cell/work Phone: |
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| How long did you work for this family: |
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| How many children were you responsible for? |
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| What were their ages when you began: |
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| What were your responsibilities? |
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| What was your schedule: |
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| Why did you leave? |
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| Name of Family #2: |
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| Street address: |
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| City: |
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| State: |
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| Zip code: |
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| Home Phone: |
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| Cell/work Phone: |
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| How long did you work for this family: |
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| How many children were you responsible for? |
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| What were their ages when you began: |
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| What were your responsibilities? |
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| What was your schedule: |
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| Why did you leave? |
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| Name of Family #3: |
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| Street address: |
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| City: |
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| State: |
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| Zip code: |
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| Home Phone: |
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| Cell/work Phone: |
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| How long did you work for this family: |
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| How many children were you responsible for? |
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| What were their ages when you began: |
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| What were your responsibilities? |
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| What was your schedule: |
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| Why did you leave? |
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| Tell us about your best experience with children: |
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| Tell us about your worst experience with children. |
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| Describe your philosophy on discipline. |
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| Describe how you would handle a situation where a 3 month old baby begins crying and will not stop. |
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| Please tell us about any other childcare experience you have (camps, daycare, etc.) |
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| Please list activities you enjoy doing with children. |
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| What are some activities you might do with a two year old? |
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| What would you say to a six year old who tells you, "You are not my mommy, I don't have to listen to you? |
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| What are you looking for in a family? (ie. Ages of children, number of children, type of relationship you want with the family) |
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| Do you prefer to work with a family where the mom or dad is not working at home? |
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| Are you willing to travel with a family? |
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| Do you have any experience with pets? |
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| Would you mind helping to take care of a family's pets? |
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| Do you have any pet allergies? |
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| Can you cook? Would you be willing to cook for the children/ the family? |
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| What other household duties would you be willing to do? |
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| Check the items that would be acceptable in a nanny position: |
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| Tell us about your family (parents, children, siblings, their occupations/activities). |
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| Are you living with your family or on your own? |
With Family Alone |
| If you have children, who cares for them on school vacations/sick days? |
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| Tell us a little bit about yourself. For example, how would your best friend describe you? |
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| What are your hobbies/interests? |
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| Describe your current job if you are employed. Why are you looking to change jobs? |
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| What are your future goals? |
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| Please list the names and phone numbers of at least 3 references for whom you have worked in childcare. If there are not three jobs like that, the references may be from other employers or academic areas. |
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| Is there anything else you feel a family should know about the qualities you have to offer their family? |
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| When you have been offered a job by a family we will conduct a background search which includes a criminal background and DMV check. Do you agree to let us do this search? |
Yes No |
| Is there anything in your background that you know will show up? |
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By clicking on the submit button, I affirm that I am the person listed above and all information provided is true in its entirety.
After hitting the submit button, you will be e-mailed a page that shows the answers you submitted. Please save or print this page for your own records.
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