Name (first & last)

Cell Phone

Major Cross Streets

Address

City

State

AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Zip Code

Work Phone

Home Phone

How would you like to receive nanny applications?

Fax   Mail E-Mail

Mother’s Occupation

Phone

Father’s Occupation

Phone

Name of children age Date of Birth Grade/School

If your children are in school, what are their hours?

 If yes, please explain

Describe your home (formal vs. Informal, house rules, etc.):

How many Bedrooms?

1 2 3 4 5 Sstairs? 1 2 3 4 5

Is smoking allowed?

Yes   No

Do you have pets?

Yes   No

If yes, please list:

Please list any health considerations of your family:

Please list any situations or people (outside of the obvious) which you do not want your children to have exposure:

Describe your family (please check all that apply):

Have you employed a nanny or au pair before?

Yes    No

If yes, what was the experience like?

Start date needed:

Summer Year Temporary  

Would you prefer:

Select One Live-In Live –Out Full-Time Part-Time Summer

Please list the hours and days your nanny will be expected to work:

Will your nanny be required to work?

Weekends Evenings Overnights

Will your nanny be required to travel with you?

Yes   No

What salary range are you offering?

Do you plan on withholding taxes from your nanny’s paycheck?

Yes   No

Do you need more information on taxes?

Yes   No

Are you open to a nanny bringing her own child?

Select One Yes No Maybe

Are you open having the nanny take your child(ren) out of the home for child related activities?

Yes   No to be continue

What activities will your nanny participate in with your child(ren)?

Please list any special skills or abilities you desire in a nanny:

Will you be providing health insurance or a stipend?

Select One Yes No Maybe

What benefits will you be providing (vacation, holidays, etc.)?

If you will be employing a live-in nanny, what accommodations will you be providing?

Do you have any other domestic help?

Yes   No

If yes, please list

What light housekeeping duties will your nanny be responsible for?

Will your nanny be responsible for any cooking?

Yes   No

if yes, please describe:

How do you handle discipline in the home?

What role does religion play in your home?

Is driving required?

Yes   No

Is the car an automatic or a standard?

Will your nanny be responsible for running any errands (Grocery shopping, Clothes Shopping, etc.)?

Who will be responsible for the child(ren) when they are sick?

How did you hear about NATION CHILDREN?