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Please complete this basic information and mail, fax, download and email, or scan it to us. We are sensitive to the fact that individuals do not want to provide personal information on-line, therefore, this Application is just the beginning of NEIGHBORHOOD NANNIES Nanny screening process. We will be talking with you in depth when we meet you personally. You need to be prepared to discuss your background, child care experience, ideas about discipline, age appropriate activities, etc. You will also have to provide your birth date, social security number, drivers license, and a list of previous addresses. Additionally you will need to sign a form allowing us to conduct a complete background check.
NANNY APPLICATION FORM
DATE______________
NAME:__________________________________________
Have you ever used, worked or earned a degree under another name? If yes, please supply all other names
_________________________________________________________
ADDRESS:____________________________________ HOME PHONE:________
____________________________________ CELL PHONE:____________
EMAIL ADDRESS: ________________________________
ARE YOU FIRST AID/CPR CERTIFIED? _____NO ______YES _______DATE
If NO you must take course
EDUCATION:
COLLEGE:______________________________________
MAJOR:________________
DEGREE OBTAINED:__________________YEAR OF GRAD.________
DATES ATTENDED__________
COLLEGE:______________________________________
MAJOR:_________________
DEGREE OBTAINED:__________________YEAR OF GRAD.________
DATES ATTENDED__________
HIGH SCHOOL:________________________YEAR OF GRAD.____________
CITY AND STATE:_______________________G.E.D./YEAR______________
OTHER EDUCATION/TRAINING/CERTIFICATES/LICENSES:
_________________________________________________________
LIST ANY CHILD RELATED COURSES, SEMINARS, etc.
_________________________________________________________
DEPENDENTS: Name, Relationship to you, Date of Birth
_________________________________________________________
_________________________________________________________
_________________________________________________________
INTEREST:
Number of hours you prefer to work weekly: ________________________________
Time of day available to work:
DAYS____________EVENINGS____________NIGHTS____________
What specific days are you available to work?__________________________________
What is the earliest time you can be at a job?____________
Latest you can stay?________________
Are you willing to work occasional weekends?____Yes ____No
____Sat.___Sun.____Day____Night____Either
Are you willing to work occasional overnights? ____Yes____No
Please describe your availability in more detail _________________________________
__________________________________________________________
What are you looking for?
___Long Term___Short Term___Occasional___On-Call___After School Care___Summer only
Are you willing to work with 2 families who want to 'Share-A-Nanny' ____Yes ____No
How long of a commitment are you able to make to a family?__________________________
Please be aware that most permanent positions require a minimum of one year commitment.
Long term only________Short term only_______ Can consider both_________
Are you looking to be a __________Live-In Nanny ________Live-Out Nanny ________Either
Are you willing to relocate?________________
When are you available to start work?______________________________________
What are you looking for as a salary?_______________________________________
Age of children preferred:
Newborn____Infants____Toddlers____Pre-school____School Age_____All ages
Number of children preferred?____
Do you have any experience with twins, triplets, etc? Describe________________________________________________
Do you have any experience working with physically or mentally challenged children? Describe________
__________________________________________________________
GENERAL:
KIND/TYPE/YEAR of car owned:_________________________________________
License plate number:_______________________________________________
Name of car insurance company:_________________________________________
Have you had any motor vehicle violations within the past 3 years? Please describe______________
__________________________________________________________
Has your license ever been suspended or revoked?____No ____Yes;
If yes, please supply dates and details __________________________________________________________
Are you authorized to work in the United States? _____Yes ____No
What languages do you read, speak, or write fluently?_____________________________
Are you physically and emotionally able to perform the functions of a nanny?___Yes ___No;
Please describe any limitations __________________________________________________________
How many days of work will your previous employers say you missed last year?________________
__________________________________________________________
Do you have any allergies? ____No ____Yes. If yes, please supply details__________________
__________________________________________________________
Are you willing to submit to a physical and drug test if required by a family?____Yes _____No
Do you swim?___No ____Yes. How well?____________________________________
Are you willing to work with a smoking family?_____Yes _____No
Are you willing to work with a family with pets?____Yes _____No
Are you willing to cook?____________Willing to do housework?_______Grocery Shopping?______
Family's laundry? ________Transport children to activities?____________Errands?_________
Have you ever been convicted of a crime? ____No ____Yes; If yes please supply dates and details______
__________________________________________________________
Have you ever been disciplined for any negative behavior on a job? ____No ____Yes;
If yes, please describe __________________________________________________________
Have you ever left a job on unfriendly terms?
If yes, please supply details_______________________________________________________
Are you on unemployment?____No ____Yes;
If yes, for how long?__________________________
Are you on disability? ____No _______Yes;
If yes, supply dates and details_______________________________________________________
Please describe your strengths and any talents you have____________________________
__________________________________________________________
How would your friends describe you?________________________________________
__________________________________________________________
Please tell us how the children you might care for will benefit by having you as their Nanny?__________________________________________________________
__________________________________________________________
Please give your reasons for applying to Neighborhood Nannies:________________________
__________________________________________________________
__________________________________________________________
Please provide name and phone number of who we should notify in case of an emergency:
__________________________________________________________
WHAT TYPE OF CHILD CARE EXPERIENCE DO YOU HAVE? Please check all that apply:
____Live-out Nanny ____Live-in Nanny____Babysitting____Day Care Center____Camp Counselor____Neighbors
____Relatives____Church/Synagogue/Gym Nursery____Teacher____School ____Other: List_______
__________________________________________________________
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CHILD CARE EMPLOYMENT HISTORY/REFERENCES: Please start with most recent.
NAME:_______________________________________________________
Complete Address:________________________________________________
Phone:_____________________________Dates Employed:________________
Ages of children and responsibilities:_______________________________________
__________________________________________________________
Will this employer give you a good reference?____Yes ____No;
If no, please describe the circumstances___________________________________________________
NAME:_______________________________________________________
COMPLETE ADDRESS:_____________________________________________
Phone:________________________________Dates Employed:_______________
Ages of children and responsibilities:_______________________________________
__________________________________________________________
Will this employer give you a good reference? ____Yes ____No;
If no please describe the circumstances___________________________________________________
NAME:_______________________________________________________
Complete Address:________________________________________________
Phone:________________________________Dates Employed:_____________
Ages of children and responsibilities:_______________________________________
__________________________________________________________
Will this employer give you a good reference? ____Yes ____No;
if no please describe the circumstances___________________________________________________
NAME:_______________________________________________________
Complete Address:________________________________________________
Phone:________________________________Dates employed:_____________
Ages of children and responsibilities:_______________________________________
__________________________________________________________
Will this employer give you a good reference? ____Yes ____No;
If no, please describe circumstances___________________________________________________
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OTHER NON-CHILD CARE RELATED EMPLOYMENT HISTORY:
NAME:_______________________________________________________
COMPLETE ADDRESS:____________________________________________________
PHONE:________________________________Dates employed:______________
Duties and Responsibilities____________________________________________
__________________________________________________________
Will this employer give you a good reference?____Yes____No;
If no, please describe circumstances___________________________________________________
NAME:_______________________________________________________
COMPLETE ADDRESS:____________________________________________________
PHONE:_________________________________Dates employed:____________
Duties and Responsibilities:____________________________________________
__________________________________________________________
Will this employer give you a good reference? ____Yes ____No;
If no, please describe circumstances___________________________________________________
NAME:_______________________________________________________
COMPLETE ADDRESS:____________________________________________________
PHONE:_________________________________Dates employed:____________
Duties and Responsibilities:____________________________________________
__________________________________________________________
Will this employer give you a good reference? ____Yes____No;
If no, please describe circumstances__________________________________________________
Please attach separate sheet if there are other employers.
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PLEASE SUPPLY THE NAMES, ADDRESSES AND PHONE NUMBERS OF 2 PERSONAL REFERENCES. THESE REFERENCES MAY NOT BE RELATIVES:
NAME:_______________________________________________________
ADDRESS:____________________________________________________
PHONE:______________________________________________________
HOW LONG HAVE YOU KNOWN THIS REFERENCE?___________ RELATIONSHIP TO YOU?______________
NAME:_______________________________________________________
ADDRESS:____________________________________________________
PHONE:______________________________________________________
HOW LONG HAVE YOU KNOWN THIS REFERENCE?__________RELATIONSHIP TO YOU?_______________
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By submitting this application I acknowledge that ALL the information provided is accurate and complete. If I am being considered for a position or am subsequently placed in a position, I accept all consequences should any of this information prove false or direct deception or omission. I also agree that I will hold the Agency or any of its representatives harmless for any liability or damages that may arise from being referred to a short term, occasional or long term job through the Agency, regardless of when, where or how these damages occurred
SIGNATURE OF APPLICANT____________________________________
Date:___________________
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