Nanny Application

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Personal Information
First Name: Last Name: Middle Initial:
Street Address:
City: State: Zip:
How long have you lived at your current address?
Date of Birth: Email Address:
Are you a legal citizen of the United States? YesNo
Phone Number
Education
School City, State Major/Minor # of Years Degree
Summary of childcare experience and training:

Are you certified in CPR? YesNo Date of Expiration:
Are you certified in First Aid? YesNo Date of Expiration:
General Health Information
Do you smoke? YesNo Date of Last Physical:
Are you allergic to cats or dogs? Cats: Yes Dogs: Yes

Do you have any health problems that could interfere with your ability to be a childcare provider? If so, please explain:

Transportation and Background Information
Do you have your own vehicle? YesNo Drivers License #:
Make/Model of Vehicle: License Plate #:
Insurance Company: Expiration Date:

Have you been ticketed for any reason or had a traffic accident in the past 5 years?
If so, please explain:

Have you ever been convicted of a crime other than a minor traffic violation? YesNo
Have you ever been indicated as a perpetrator in a child abuse/neglect investigation? YesNo

If the answer to either or both of the above is yes, please explain:

Employment History (Please list employment chronologically from present.)
Employer Name #1: Address:
Phone: Times to call:
Number of Children: Children's Ages:
Employed From: To:
May we contact this employer? YesNo To:

(If Yes, list phone number and contact name. If No, state reason.):

Positions Held:

Job Duties:

Reason for Departure:

Employer Name #2: Address:
Phone: Times to call:
Number of Children: Children's Ages:
Employed From: To:
May we contact this employer? YesNo To:

(If Yes, list phone number and contact name. If No, state reason.):

Positions Held:

Job Duties:

Reason for Departure:

Employer Name #3: Address:
Phone: Times to call:
Number of Children: Children's Ages:
Employed From: To:
May we contact this employer? YesNo To:

(If Yes, list phone number and contact name. If No, state reason.):

Positions Held:

Job Duties:

Reason for Departure:


What type of position are you looking for? (Mark all that you would accept.)
Full-time (live-out, 30 hrs + per week) Yes Part-time (0-29 hrs per week on regular schedule) Yes
Sitter (occasional) Yes Live-in (40 hrs + per week) Yes Summer Nanny/Companion: Yes
Please indicate start and end dates for Summer Nanny position: Start
End
How many hours do you want to work per week?

Please indicate below the times you are available to work as well as your class schedule or any other regular events that would prevent you from working:

Week Day Class Schedule / Ongoing Commitments: Times Available for Work:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Applicant Signature: Date:
Agency Signature: Date:

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