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PERSONAL INFORMATION

Name (First/Last):

Street Address:
City: State: Zip:

DOB: SSN#: EIN#:

Home Phone:

Cell Phone:

Email:

FAMILY INFORMATION

Marital Status: Single Married Separated

Do you have any children? Yes No

Number of children:

Have you ever been convicted of a felony? Yes No

EDUCATION

Name of High School:

Year Graduated High School:

Name of College:

Year Graduated College:

Are you trained in CPR? Yes No

Are you trained in First Aid? Yes No

Are you able to work with a special needs child? Yes No

PRIOR EXPERIENCES

List the ages of children that you have cared for:

List your prior work experience:
(Please list using dashes to separate each experience.)

JOB PREFERENCES

Salary desired:

Work hours:

Preferred days off:

Desired number of children:

Children age preference:

Sex of children preferred: Male Female Either

Please tell us why you think you will be suitable for this position:

Interested in position (check all that apply):

Companion: Mothers helper: Light housework: Complete housework:
Driving: Nanny: Prepare meals: Running errands: Live-in: Live-out:

MEDICAL HEALTH INFORMATION

Do you have any current health, physical problems, or limitations? Yes No

If you answered "yes" above, please explain:

Do you smoke? Yes No

Can you work with clients who smoke? Yes No

Are you currently taking any prescribed medications? Yes No

Do you have any special medical considerations? Yes No

When was your last check-up?

AVAILABILITY

What is your availability? (select all that apply)

Live In: Live Out:

Full Time: Part Time:

Days: Evenings: Weekends:

How flexible are you: Very Some Not at all

Are you willing to travel with family during their vacations? Yes No

COMMITMENT

What can you commit to? (select all that apply):
Long-term (1 year or more) Short-term (6 months or less) Summer

Would you consider a longer stay with one family? Yes No

DRIVING

Can you drive? Yes No

If not, are you willing to learn how to drive? Yes No

Why would you be willing to do childcare? Please explain:

Are you currently considering other types of jobs? Yes No

Do you wish to be in a home with a working or non-working mom? Yes No Doesn't matter

Do you want complete direction from the parents on the children's daily activities? Yes No

FAMILY

How many children are you comfortable working with?

What age group are you most comfortable with? (select all that apply)
Infant: Toddler: Preschool: School Age: All:

What skills do you feel comfortable performing? (select all that apply)
Changing Diapers:       Bathing the children:      Preparing meals for children:
Fixing school lunches:    Laundry for children:       Grocery shopping:
Household errands:       Taking children to activities:

What are your feelings on discipline? Please explain:

List any special skills that you could teach the children (Languages, piano, swimming, etc.):

REFERENCES

List your references: (Please list at least 3)

Reference 1 Name:

Address:

City: State: Zip:

Phone:

Duration worked for:

Reference 2 Name:

Address:

City: State: Zip:

Phone:

Duration worked for:

Reference 3 Name:

Address:

City: State: Zip:

Phone:

Duration worked for:

Typed Signature: Date signed:

Signature: ________________________________________________________ Date: __________________

If submitting form via this online form, you will be asked to sign when visiting our office.

Please read the Policies & Procedures for Nannies then place an "X" in the box if you agree.
You will not be able to proceed if you do not agree with the Policies & Procedures.

I agree with the Policies & Procedures for Nannies.

View the Policies & Procedures for Nannies

If you feel uneasy submitting your personal information over the Internet, please print this form and send it to us via postal service. By submitting this form via Internet, you indemnify Dubols of any responsibilities for the misuse of personal information.