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Client Application Form

The required fields are indicated with *
Please respond to questions in 2-3 sentences

Request Date:

* Nanny/Provider is required
Hold down the "ctrl" or "shift" keys to select multiple choices

* Type of Nanny / Provider required:
Hold down the "ctrl" or "shift" keys to select multiple choices
* Type of work for Nanny / Provider:
- Select One -
Note: Based on this choice you will need to submit the corresponding Agreement once this form is completed.
PRIMARY CONTACT INFORMATION
* First Name of primary contact:
* Last Name:
* Home (and mailing) Address:
* City
* State  in United States
* Zip Code:
* Home Phone:
Work Phone:
Cell Phone:
Pager:
Fax Phone:
E-Mail:
Age:
Place of work and occupation:
Work schedule:
Briefly describe personality type:
SECONDARY CONTACT INFORMATION
First Name of secondary contact:
Last Name:
Home (and mailing) Address:
City
State  in United States
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
Pager:
Fax Phone:
E-Mail:
Age:
Place of work and occupation:
Work schedule:
Briefly describe personality type:
EMERGENCY CONTACT INFORMATION
Who will be responsible for children / elder in the event of an emergency (such as the provider becoming ill) during the time you are away? - Someone other than the primary / secondary contacts.
* Describe your child care/provider needs & activities:
* Are there any legal issues, special circumstances, or persons that children should not be in contact with while in the care of the Nanny / Provider? (ie; custody, divorce, or sickness)      YES      NO
If yes, please specify:
Date you would like nanny/provider to start:
Specify exact daily schedule in 24 hour format:
Monday From: To:
Tuesday From: To:
Wednesday From: To:
Thursday From: To:
Friday From: To:
Saturday From: To:
Sunday From: To:
Other
Which two days will she / he have off per week?
Names, ages, and dates of birth of your children or elder person:
NAME AGE D.O.B.
NAME AGE D.O.B.
NAME AGE D.O.B.
NAME AGE D.O.B.
* Do you require a non-smoker?      YES      NO
* Do you have family pets?      YES      NO
If yes, please specify
* Will the nanny/provider be caring for the pets?      YES      NO
* Do you have a swimming pool?      YES      NO
* Do you require a swimmer?      YES      NO
Will your nanny/provider perform
the following duties:
Laundry  Cleaning  Errands  Driving 
Meals  Toileting  Dressing  Bathing 
Hygiene  Medication  Lifting & Assisting 
Other 
* Do you require the nanny/provider to tend a wood or coal stove?      YES      NO
* Do you require the nanny/provider to transport in your auto?      YES      NO
* Stick shift?      YES      NO
* Do you require the nanny/provider to have his or her own vehicle for transporting?      YES      NO
---> NOTE: Mileage or gas reimbursements required with use of nannies/providers own car.
* Do you have a religious preference for your nanny/provider?      YES      NO
What kind of household do you run?
* Please give us the salary range you are willing to pay:   $   -   $
* Health Insurance, Health Club, 401K, etc.?      YES      NO
Please provide brief description of your home:
Please provide directions to your home from the nearest major highway.
Additional information about your children or elder:
Include grade level in school, special physical or emotional conditions, or anything else you would like to include.

* Have you used an agency before?

* How did you hear about us?(please describe)

 YES      NO

What sort of care arrangements have you used in the past?
Why do you want a nanny / provider
Which meals do you plan to have the nanny / provider prepare?
* Will the nanny / provider travel with the family?      YES      NO
If nanny / provider will be traveling describe when.
* Is a vehicle available to the nanny / provider during any of her / his off time?      YES      NO
If YES, when would vehicle be available?
Please describe the nanny / provider living accommodations (separate entrance, TV, own bath, radio, etc)
Master Card, Visa, Bank Check
By checking the box below I certify that I agree to the terms of the Agreement, and that the facts contained in this application are true and complete to the best of my knowledge. I authorize The Nanny Solution, inc. to start my search and agree to the terms of the agreement on the previous page.


Send the form. You will then receive a confimation page.


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