Hire a Nanny Fields with * are required. Parent/Guardian Name(s)* First Last First Last Primary Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Home FaxBusiness Fax 1Business Fax 2Email Address 1* Email Address 2 Cell Phone 1* Cell Phone 2 Number Number Work Phone 1 Work Phone 2 Work Phone 1Work Phone 2Where are you employed, and what is your title?Name* Name Organization* Organization Title* Title Time you leave in the morning:*Time you leave in the morning:Time you return home:*Time you return home:Frequency and duration of travel:*Frequency and duration of travel:Description of Family/Household(1) Name* Sex*MaleFemaleAge*Date of Birth*Relationship*(2) Name SexMailFemaleAgeDate of BirthRelationship(3) Name SexMailFemaleAgeDate of BirthRelationship(4) Name SexMailFemaleAgeDate of BirthRelationship(5) Name SexMailFemaleAgeDate of BirthRelationshipReligion(s) of HouseholdLanguage(s) Spoken at Home*Smoke Free Environment?*YesNoDo any family members have special needs?*YesNoIf yes, please explain:Have you ever hired a nanny or any other household employee?*YesNoOtherIf yes, may we contact them for a reference?YesNoOther Nanny CommentsDo you currently employ other staff?*YesNoIf yes, please describe:Are there any pets in your home?*YesNoIf yes, please describe:Please describe your home, including size:*Please describe your ideal home environment/ambience:*Is your home near a bus line?*YesNoType of community:*UrbanSuburbanRuralType of Position(s) Needed:*Ideal personality and characteristics:*Please check what type of candidate best describes what you are looking for:*You may check more than one category. Young, Single Persons: They have extensive babysitting and/or daycare experience and are interested in working as a nanny for a year or two. These nannies may currently have a job that does not offer the same personal rewards that being a nanny and caring for children would offer or they may be taking a break from college or suspending a long-term commitment to another career. These nannies are usually active, energetic and open to new experiences. Older, more Mature Persons: They may have raised a family of their own and who are drawn to in-home child care because they enjoyed caring for their own children or may have watched children in their own home while raising their children. Education, background and life experiences are varied with this type of nanny candidate. Individual Professionals and Specialists: These Individuals consider themselves child care professionals and specialists. Some nannies have degrees in early childhood education or elementary education or have a specialized nanny training certificate. Many have worked several years as nannies. Persons in this group consider being a nanny their career. Other If other, please describe:Briefly describe the personalities, characteristics and lifestyle of the members of your household and a typical day:*Please describe the main duties required:*Is driving a requirement for this position?*YesNoIf yes, please explain when and where the nanny will be required to drive:Are you comfortable with the nanny bringing your child(en) to places like the park, children's museum, story hour at the library, the zoo or play dates with other children?*YesNoAre you opposed to a nanny that would bring along their own child?*YesNoIf no, what ages would be ideal?Live in OnlyPlease describe the living quarters for the nanny and what will be provided (example: TV, computer, vehicle, health club membership):Employee Benefits(Please fill this out to the best of your knowledge and we will discuss this in detail at our meeting and help customize a job description.) Salary Range:*Number of paid sick/personal days:*(typically 3-5) Number of paid vacation days:*Normally 1 week for part time and 2 weeks for full time.Paid Holidays:*Please list. Will you provide "tax free" dollars towards health insurance for the nanny?*YesNoUndecidedApproximate Amount:(the average provided is anywhere from $100.00-$150.00/month) Will a vehicle be provided to use during working hours?*YesNoIf no, will gas money be provided?YesNoWork ScheduleIs this a Temporary (4 months or less), On Call (2 weeks or less) or Long Term (1 year or longer) Position?*Approximate Start Date:Approximate End Date (for On Call or Temporary):Approximate Start Time (hh:mm am/pm):*Approximate End Time (hh:mm am/pm):*Hours Per Day/Number of Days Per Week?*Scheduled Days Off:*Please provide us with any other additional information you would like us to know about your family or details about the position:How did you hear about us?*Name of Referral:CommentsThis field is for validation purposes and should be left unchanged.