Nanny Services, Child Care Services

Click here for Printable Version of FAMILY APPLICATION FORM

DATE_____________

PLEASE CHECK THE BLANKS, COMPLETE THE FORM, where applicable, and return with the appropriate NON-REFUNDABLE APPLICATION FEE.

________PRN: CHILD CARE ON AN 'as needed' BASIS--OCCASIONAL DAYS, EVENINGS, VACATION COVERAGE, etc.

________PERMANENT--FULL OR PART TIME CARE, (ANY NUMBER OF HOURS PER WEEK ON A CONSISTENT BASIS)

APPLICATION FEE: PERMANENT FT/ PT: $ 125.00 PRN APPLICATION FEE: $ 75.00
****************************************************************************************************************************

PERSONAL INFORMATION:

Family's Last Name:__________________________________________________

Address: Please list both if parents do not live together and share custody at different homes

_____________________________________________________________

HOME PHONE NUMBER: Please list both if parents do not live together_______________________

PARENT #1 NAME:________________PARENT # 2 NAME:____________________

AGE: ___________________________ AGE: ____________________________

PROFESSION:___________________ PROFESSION:________________________

COMPANY: _____________________ COMPANY:__________________________

BUS. ADDRESS:_________________ BUS. ADDRESS:_______________________

___________________________________________________________

BUS. PHONE: ___________________ BUS. PHONE:________________________

CELL PHONE: ___________________ CELL PHONE::_______________________

E-MAIL:_________________________ E-MAIL:___________________________

Do either parent work from home? ____NO _____YES _____________WHO
Does any family member smoke in home? ____NO _____YES _________WHO

CHILDREN:

CHILDREN INFORMATION

NAME____________________________AGE______ DOB________SEX__________

Are any of the above children on medication, or are there any aspects of their physical or emotional development
that require special attention, or may impact on the care provided? If yes, please indicate which child and describe:

_____________________________________________________________

ANTICIPATED NEEDS FOR NANNY SERVICES:

Nanny's projected scheduled work days and hours:___________________________________

_____________________________________________________________

Will additional evening or weekend hours ever be required?_______Yes __________NO

If yes, when and how often?_______________________________________________

How long of a commitment do you have in mind for the nanny?____________________________

Do you have an age range preference for a nanny? ____No ____19-30 years ____30-50 ____50 plus if healthy

ROOM, BOARD AND BENEFITS: Please check as appropriate for your situation:

The following will be provided for the Nanny:

Private bedroom____FURNISHED____UNFURNISHED____ USE OF AUTO/AUTO INSURANCE:____

A bathroom____PRIVATE____SHARED

CAR FOR ON DUTY____ OFF DUTY____
IF YES_____automatic ______stick shift

HEALTH INSURANCE: ____FULL ____PARTIAL_____NEGOTIABLE

QUESTIONNAIRE

Does the Nanny need a Driver's License? ___Yes___No
Does the Nanny need to have her own car? ____Yes____No
Will the Nanny be transporting your children to outside appointments or activities?____No ____Yes;
If yes, describe:_____________________________________________________________

_____________________________________________________________

How many paid holidays will the Nanny be offered?____________________________________

How many paid vacation weeks will the Nanny be offered?_________________________________

What range of pay are you offering the Nanny?_____________________________

Are you offering any other benefits?_____________________________________________

What is the date you need the Nanny to start work?____________________________________

Do you have a regular maid/housekeeper? ____Yes _________________How Often? ______No

Do you have any pets? _____No _____Yes; if yes, please describe __________________________

Do you have a pool?____Yes ____No ________Belong to a country club or swim club?
Does the Nanny need to be a swimmer_____Yes _____No _______Preferable

Do you anticipate the Nanny traveling with you?____No ____Yes _______Maybe
If yes, please give brief description of the type and frequency of travel required, as well as if the Nanny needs a passport

_____________________________________________________________

Please specifically list and describe all child care and associated responsibilities you will expect of the Nanny:

_____________________________________________________________

Please list any personality characteristics you prefer NOT to have in a Nanny:

_____________________________________________________________

Is there any additional information about your family's situation that we should know to help us better assist you with
your nanny search? If yes, please describe below:___________________________________

_____________________________________________________________

Please either download this Application and mail it to us, along with your Application Fee to NEIGHBORHOOD NANNIES, 5 N. Haddon Ave. Haddonfield, N.J. 08033 or download it and email it to us at info@neighborhoodnannies.net, or fax it to 856-216-0600. If you are emailing or faxing it please send your Application Fee under separate cover to the address listed here.

REMITTANCE OF THIS APPLICATION AND APPLICATION FEE IS ACKNOWLEDGED AS YOUR ACCEPTANCE AND AGREEMENT TO THE TERMS OUTLINED IN OUR AGENCY/ NANNY SERVICES AND FEES AND GUARANTEES INFORMATION, WHICH DESCRIBES ALL NEIGHBORHOOD NANNIES POLICIES, COSTS, FEES, AND HOURLY RATES.

_____________________________ _____________________________
FAMILY REPRESENTATIVE'S SIGNATURE FAMILY REPRESENTATIVE'S SIGNATURE

______________________________ ______________________________
DATE DATE