Employer Application | A Nanny Connection

Parent & Contact Information

Mother's Name

Mother's Occupation

Work Phone

Mobile Phone

Father's Name

Father's Occupation

Work Phone

Mobile Phone

Hours Away From Home

Street Address

City

State

ZIP

Home Phone

Children

Number of Children

Child 1

First Name

Last Name

Age

Gender

Female Male

Child 2

First Name

Last Name

Age

Gender

Female Male

Child 3

First Name

Last Name

Age

Gender

Female Male

Do any of your children have special needs?

No Yes

If yes, please describe

Position & Schedule

Position offered is

Full-time Live In Full-time Live Out Part-Time Permanent Summer Placement Temporary

Do you live in a

House Condo Townhouse Apartment

Does anyone else live in the home?

Yes No

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

Nanny needed from

Nanny needed to

Please indicate nanny's hours and days off

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Driving & Policies

Will your nanny be driving?

Yes No

If yes and vehicle is provided, what restrictions/responsibilities?

If yes, is vehicle automatic or manual?

Automatic Manual

If nanny's own car is required, what reimbursement arrangements?

If driving children, please indicate all required

To school From school To activities From activities To friends' house From friends' house

Policy regarding nanny receiving visitors, phone calls, using TV, etc.

Will childcare needs differ during school vacations/holidays?

Yes No

If yes, please explain

Will you provide nanny living space?

Yes No

If yes, please describe

Salary & Benefits

Salary Range

Monthly range:

From

Weekly range:

From

Hourly:

From

How often will nanny be paid?

Monthly Weekly Daily

Benefits offered

Medical Dental Vacation Sick leave

Other benefits

Housework & Meals

Will your nanny be required to do housework?

Yes No

If yes, what housework duties?

Children's rooms Master bedroom Laundry Mopping Vacuuming Dusting Misc.

Will your nanny be responsible for cooking/preparing meals?

Yes No

If yes, what meals?

Breakfast Morning Snack Lunch Afternoon Snack Dinner Evening Snack

Additional Information & References

Do you have a family pet?

Yes No

Pet type

Pet name

Will the nanny be responsible for pet care?

Yes No

Nanny's primary responsibilities

What will a typical day look like for your nanny?

Additional comments, concerns, or special needs

Character References

Reference #1

First Name

Last Name

Phone

Reference #2

First Name

Last Name

Phone

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.

Your Name

Date