Parent’s Application

Employer Application

In order to submit form you must complete all required fields. Please check to make sure all required fields have been completed prior to submitting. Please also complete and submit Employer Agreement at same time. Thank you.

Mother's Name

Mother's Occupation

Work Phone Number

Mobile Phone Number

Best Time to Call

Hours Away From Home

Father's Name

Father's Occupation

Work Phone Number

Mobile Phone Number

Hours Away From Home

Address

Street, City, State & Zip

Number of Children

Child 1 Name, Gender and Age

Child 2 Name, Gender and Age

Child 3 Name, Gender and Age

Child 4 Name, Gender and Age

Child 5 Name, Gender and Age

Child 6 Name, Gender and Age

Do any of your child(ren) have special needs?

If yes, please describe

Position offered is

Do you live in a house, condo, townhouse or apartment?

Does anyone else live in the home other than the individuals listed above?

If yes, please indicate name, age and if they will be in the home during the nanny's hours

Dates you need a nanny: (from - to)

What are the nanny's hours and days off

Will your nanny be driving

If yes, and vehicle is provided, what restrictions and responsibilities will you expect of your nanny?

If yes, is the vehicle automatic or clutch?

Is your nanny's own car required for use?

If so, what reimbursement arrangements will be made?

If driving children, please indicate when required:

ex. To school, from school, to activities, from activities, to friends' homes, from friends' homes

What is your policy regarding the nanny receiving visitors, phone calls, using the television, stereo, etc.?

Will your childcare needs differ during school vacations and holidays?

If yes, please explain.

Will you provide your nanny living space?

If yes, please describe.

Will you provide a private bedroom and / or bath?

What is the salary range?

Indicate Monthly, Weekly and Hourly

How often will nanny be paid?

Please indicate any benefits you will offer your nanny

Medical, Dental, Vacation, Sick Leave, etc.

Will your nanny be required to do housework?

If yes, what housework duties (Children's Rooms, Master bedroom, Laundry, Mopping, Vacuuming, Dusting, Misc.)

Will your nanny be responsible for cooking meals?

If yes what meals? (Breakfast, Snack, Lunch, Dinner)

Do you have a family pet?

If yes, what type of pet? What is the pet's name?

If yes, will the nanny be responsible for the pet's care?

Please describe what your nanny's primary responsibilities will be

Please describe what a typical day will be like for your nanny

Please indicate any additional comments, concerns or special situation or needs

Please provide two character references

Please provide name and phone number

Name and Date

By clicking Submit I agree that I have completed this application as accurately and precisely as possible. I also have read and agree to the terms in the Employer-Agency Agreement. I understand that any of the aforementioned references can and will be contacted for verification of this information.

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