Family Application Form

Personal Information

First Name

Last Name

Home Phone

Email Address

Address

City

State

Zip Code

First Parent Information

First Name

Last Name

Cell Phone

Occupation

Employer

Working Hours Per Week

Office Address

Office City

Office State

Office Zip Code

Office Phone

Office Fax

Second Parent Information

First Name

Last Name

Cell Phone

Occupation

Employer

Working Hours Per Week

Office Address

Office City

Office State

Office Zip Code

Office Phone

Office Fax

Child Information

Indicate the number of children at your home.

Is there any child with special needs?

Yes No

If yes, please describe.

Are you expecting a child in coming months?

Yes No

If yes, when?

What kinds of activities do you and your child/children enjoy?

Do you have pets at home?

Yes No

If yes, list type and number of pets.

Nanny Requirements

If a Live-In, please describe the living accommodations

Time when nanny is needed:
To

Comments on Time

If live-in, is there a car for the nanny to drive?

Yes No

Do you require your Nanny to drive?

Yes No

If yes, will you provide Nanny with Car?

Yes No

Comments on Car

Nanny Duties

Describe Job duties of the Nanny:

  Housekeeping
  On-call baby sitting
  Mother's helper
  Baby nurse
  Child care only

  Cooking
  Dishes
  Ironing
  Household tasks
  Driving Children

  Laundry
  Pet care
  Overnights occasionally
  Dusting
  Other

If other, please describe.

Nanny Preference and Payment

Is there any age preference for the Nanny?

Yes No

If yes, please specify

Nanny will be paid:

Hourly Weekly Monthly

How many paid leaves will be given to the Nanny?

Have you ever had a nanny before?

Yes No

If yes, please describe your experience with that nanny. Was it a positive experience?

Please explain any situations that we should be aware of that will help us find the right nanny for you.

Describe the type of person you and your family would want most as a nanny.

Depict the job duties of the Nanny on a typical day:

Please give additional remarks on your requirement for a nanny that have not been previously mentioned.

Emergency Contact

Contact 1

Contact Name

Contact Phone

Contact Relationship

Contact 2

Contact Name

Contact Phone

Contact Relationship

Contact 3

Contact Name

Contact Phone

Contact Relationship

Submit