First Name
M.I.
Last Name
Address Line 1
Address Line 2
City
State
- Select -
Alabama
Alaska
Arizona
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Maryland
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Ohio
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Town
E-mail Address
Day Phone
Evening Phone
Bold
= Required field
Date (mm/dd/yyyy)
Maiden Name
Cell Phone
Date of Birth (mm/dd/yyyy)
High School Name
City
State
Dates Attended From:
To:
Yes
No
Graduate?
College Name
City
State
Dates Attended From:
To:
Yes
No
Graduate?
Other Education
City
State
Dates Attended From:
To:
Yes
No
Graduate?
Describe any other type of service or training that was childcare related
Describe child related volunteer work
Describe non-child related volunteer work
Do you plan to further your education? Please explain
When are you available to start work? (mm/dd/yyyy)
What hours are you available to work?
Do you have any other commitments we should know about?
Yes
No
If all goes well, would you be willing to renew your contract with the family after a year?
Describe your previous experience with children: How has that helped you prepare for a job like this?
Would you be willing to do the following (if applicable):
Preparing Meals
Light Housekeeping
Laundry
Grocery Errands
Running Errands
Other
Yes
No
Would you work in a house with pets?
Yes
No
Do you smoke?
Yes
No
Can you swim?
Yes
No
Would you be willing to accompany a family on vacation if needed?
Yes
No
Does your family support your decision to become a nanny?
Yes
No
Do you speak any foreign languages?
If so, which ones?
What interests you most about a nanny job?
What interests you least?
Yes
No
Do you have a car?
Make / Model / Year
Yes
No
Are you insured?
Yes
No
Do you need health insurance?
Yes
No
Will you be getting health insurance on your own?
What salary range do you expect?
Yes
No
Do you need taxes filed to prove your income?
Please check all you are experience working with:
Special Needs
Multiples (twins, triplets, etc.)
Infants as young as 3 weeks
Toddlers
Pre-K
School-age
Night Nursing
If you have experience working with special needs, please explain
Marital Status
Yes
No
Do you have children?
If yes, what ages?
Please check all the following that apply:
Take children to work?
Smoker?
Do you drive?
Are you insured?
CPR Certified?
First Aid training?
Own your own car?
Driving violations?
Yes
No
Do you have any physical limitations that could affect your work?
If yes, please explain
Please list all athletic abilities or knowledge that can be taught to children
Yes
No
Do you have a criminal record?
If yes, please explain
Yes
No
Are you involved in any psychological treatment?
If yes, please explain
Yes
No
Do you have any allergies?
If yes, please explain
Yes
No
Would you be willing to do household duties?
Please list
Yes
No
Is there an age group that you will not work with?
If yes, please explain
Why did you choose a nanny career?
Please list any hobbies or interests
Please list any organizations you belong to
What are your strongest points in working with children?
What are your weakest points in working with children?
What is your approach to child rearing?
Please list types of discipline you use
Yes
No
Can you commit to a full year of employment?
If no, how long can you commit?
Briefly describe what your childhood was like and what types of things were important to your family
What is your overall view of children?
Please check all that apply regarding your work schedule
Full Time
Part Time
Live In
Live Out
Week
Overnight
Ongoing
Please list preferred areas to work
1
2
3
4
Yes
No
Are you willing to relocate?
Date available to start (mm/dd/yyyy)
Available schedule - Please put your most consistent schedule needed
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Employer Name
Address
Phone Number
Supervisor's Name
Your Position
Reason for Leaving
Dates Worked
From (mm/dd/yyyy):
To (mm/dd/yyyy):
Employer Name
Address
Phone Number
Supervisor's Name
Your Position
Reason for Leaving
Dates Worked
From (mm/dd/yyyy):
To (mm/dd/yyyy):
Employer Name
Address
Phone Number
Supervisor's Name
Your Position
Reason for Leaving
Dates Worked
From (mm/dd/yyyy):
To (mm/dd/yyyy):
Name / Occupation
Address
Day Phone / Evening Phone
Name / Occupation
Address
Day Phone / Evening Phone
Name / Occupation
Address
Day Phone / Evening Phone
According to the application material I have read, the above information has been filled out accurately and to the best of my knowledge.
As a nanny place by Nanny Placement Service, Inc., I will not begin employment until the family has satisfied payment for the services of Nanny Placement Services, Inc.
Type Your Full Name
Today's Date (mm/dd/yyyy)
Yes
No
Are you willing to provide a statement from your doctor stating that you are mentally and physically able to work as a caregiver?
Education
Nanny Placement Service Questionnaire
General Information
Work Schedule
Employment History
Child Care References
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