Please use this form to apply for inclusion in our nanny referral service.
Required fields are marked with a *
emergency contact name:
emergency contact phone:
date of birth:
nationality:
how long have you lived in the U.S.?
have you lived in any other country/state in the last three years?
Yes
No
do you have a social security number?
Yes
No
do you have a green card or working visa?
Yes
No
do you have a valid driver's license?
Yes
No
other than English, list any languages that you speak:
highest level of education:
High School Diploma
Some College
College Two-Year Degree
College Four-Year Degree
any courses in childhood education and development?
Most families seek a nanny who is able to make a one year commitment. At the time you are ready to start working as a nanny, will you be able to make a 1 year commitment?
Yes
No
Job Specific Information
position applying for:
Live In
Live Out
Part Time
Full Time
when can you start work?
earliest start time:
latest end time:
working days sought:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
specific comments:
working hours sought:
specific comments:
do you have a car?
Yes
No
In what capacity of childcare do you have experience in?
(Live out nanny, live in nanny, relatives, camp counselor, preschool teacher, teacher, church nursery, day care center, etc...)
how many years of experience do you have?
what age of children do you have experience caring for?
have you ever had experience with children with special needs, handicaps?
Yes
No
what is the maximum number of children, regularly part of household, you a willing to care for?
Are you experienced and willing to help with the following household chores should they become part of your job description?
(General Housekeeping, preparing family meals, grocery shopping, laundry, ironing, running errands, etc)
Yes
No
are you a parent?
Yes
No
how would you rate your overall health?
please complete this sentence: "I am..."
what are your hobbies and interests?
please list any physical or psychological problems you have/have had in the past:
are you First Aid certified?
Yes
No
date certified:
are you CPR certified?
Yes
No
date certified:
if you are not First Aid and CPR certified, are you willing to become certified?
Yes
No
do you know how to swim?
Yes
No
do you smoke?
Yes
No
do you drink?
Yes
No
Have you ever had a substance abuse problem? If yes, how long ago?
have you ever been convicted of a crime, felony or misdemeanor?
Yes
No
are you comfortable working with a family who has pets?
Yes
No
$ to $ per week to start. Salary negotiable?
Firm
Negotiable
Reference Information
Give names and complete mailing addresses of at least three families you have baby-sat or nannied for:
Family #1
name:
address:
city:
state:
phone number:
how long did you work for this family?
how many children did you care for?
what were their ages when you began?
Family #2
name:
address:
city:
state:
phone number:
how long did you work for this family?
how many children did you care for?
what were their ages when you began?
Family #3
name:
address:
city:
state:
phone number:
how long did you work for this family?
how many children did you care for?
what were their ages when you began?
