Fields marked with a white asterisk* are required to submit this form.

*Mother's First Name:

*Last Name:

Middle Initial:

*Title:

*Spouse's First Name:

* Last Name:

Middle Initial:

*Title:

*Street Address:

*City:

*State:

*Country:

*Zip Code:

*Home Phone:

Mother's Cell Phone:

Spouse's Cell Phone:

Fax:

*Email:

*Emergency Contact Name:

*Phone Number:

Cell Phone:

*Address:

*Mother's Highest Level of Education:

*Spouse's Highest Level of Education:

*Spouse's Employer:

*Address:

*Work Phone:

*Work Hours:

*How much travel does your job require:

*Mother's Employer:

*Address:

*Work Phone:

*Work Hours:

*How much travel does your job require:

*Desired Nanny Starting Date:

*Will a vehicle be provided? Yes No

If yes, please describe vehicle:

*Does anyone in the home smoke? Yes No

*Is smoking allowed in the home? Yes No

If the religion of your nanny is of concern, please state your religion:

*Do any family members have health problems? Yes No

If yes, please describe:

*Do you own or rent your home? Own Rent

*Type of Residence: Private Residence Apartment Townhouse

*Approximate square footage:

*Will you provide health benefits? Yes No

Describe nanny's living arrangements:

*Please check all that are appropriate.

Dress Feed Play Interact Teach Bathe Instruct the child/children

Light housekeeping related to the child's care.

Please specify

Heavy or Light Housekeeping unrelated to the child's care.

Please specify

Shop for groceries, clothing, etc.

Take the child on entertaining and/or educational outings

Take the child to medical appointments, lessons, schooling, etc.

Maintain a journal of daily activities

Other

Please specify

*Do you have a regular housekeeper? Yes No

*Do you have other staff members? Yes No

Please specify

*Will the nanny travel with you? Yes No

If yes, where and how often?

*Do you have any pets? Yes No

Name of pet or pets:

*Have you ever employed a child care provider? Yes No

If so, please describe your experiences with the provider(i.e. how long did each one stay, where did you obtain the nanny from, why did they leave?):

Please share any additional comments of favorable/unfavorable experiences with the prior nannies and/or childcare:

*List any specific qualities that you are looking for in a nanny (i.e. swimmer, athletic, college background, CPR certification):

*Will overtime be required? Yes No

*Please indicate days and hours expected of nanny:

*Total weekly hours:

*Estimated Weekly or Hourly income for nanny:

*Will the nanny need to stay overnight if you are not hiring a live in? Yes No

If yes, please explain under what circumstances it will be required?

*Please provide the name and contact information of at least two references:

*How did you hear of this company?

"By Submitting this application, I certify that all information included in this application is accurate to the best of my knowledge. I agree to pay the $250 application fee upon submission of this application. I understand that knowingly withholding information or providing false information is grounds for termination of contract."