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Nanny / Provider Application

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


Date:
Social Security Number:
* First Name:
* Last Name:
* Address:
* City:
* State:  in United States
* Zip Code:
* Phone:
Work Phone:
Cell Phone:
Pager:
Fax Phone:
What phone number can you be reached at
between 10:00 A.M. and 4:00 P.M?
E-Mail:
Languages Other than English:
How did you hear about our agency?

* WHAT TYPE OF PROVIDER ARE YOU APPLYING TO BECOME?
Hold down the "ctrl" or "shift" keys
to select multiple choices

 

 

 

* WHAT KIND OF EMPLOYMENT ARE YOU INTERESTED IN?
Hold down the "ctrl" or "shift" keys
to select multiple choices

Are you able to care for infants?    YES      NO

Experience?

  
Are you able to care for toddlers?    YES      NO

Experience?

  
Are you able to care for adolescents?    YES      NO

Experience?

  
Are you able to care for elderly?    YES      NO

Experience?

  
*When are you available to begin employment?
Specify exact daily schedule you are able to work in 24 hour format:
Monday:
AM Afternoon PM     From: To:
Tuesday:
AM Afternoon PM     From: To:
Wednesday:
AM Afternoon PM     From: To:
Thursday:
AM Afternoon PM     From: To:
Friday:
AM Afternoon PM     From: To:
Saturday:
AM Afternoon PM     From: To:
Sunday:
AM Afternoon PM     From: To:
Other
How many minutes are you willing to travel to work?
* What is your minimum starting salary?     $
* Do you smoke cigarettes?      YES      NO
* Do you have experience in running a household?      YES      NO
* What tasks are you willing to perform?
(cleaning, cooking, shopping, gardening, etc.)
* Do you object to pets?      YES      NO
* Do you have any allergies to animals or other substances?
* Are you certified in CPR?      YES      NO
* Minor First Aid?      YES      NO
* Need to recertify?      YES      NO
* Any other Certifications?
* What hobbies and sports do you enjoy and are currently doing?
 Are you willing to care for children who may have special disabilities behavioral or learning problems?      YES      NO
* Do you feel you can run a household of 1, 2, 3, 4, or more children? 1     2     3     4     More than 4    
* Have you ever been arrested for any type of crime?      YES      NO
* Have you ever been treated by a psychiatrist or psychologist?      YES      NO
* Are you presently under circumstances that would limit or prevent you from performing a complete range of activities? (e.g. lifting, kneeling, bending, running, jumping, swimming, or dealing with stressful situations?      YES      NO
If yes to any of the three above questions - please explain here:
* Do you own an automobile?      YES      NO
If yes please describe your vehicle
Driver's License # and state?
* Have Insurance?      YES      NO
 Do you feel confident enough in your driving skills to transport children/adults in an automobile?      YES      NO
* Have you ever been convicted for a child or other crime?      YES      NO
* Have you ever been brought into the police station for anything?      YES      NO
EDUCATION
Please include dates, schools, graduation year, training programs attended, diplomas or certificates and child care experience.

*  1. Degree/Certification School/College/University Description
From To Year Graduated
   2. Degree/Certification School/College/University Description
From To Year Graduated
   3. Degree/Certification School/College/University Description
From To Year Graduated
   4. Degree/Certification School/College/University Description
From To Year Graduated
   5. Degree/Certification School/College/University Description
From To Year Graduated
EMPLOYMENT HISTORY PAST FIVE YEARS - MOST RECENT EMPLOYER FIRST:
Employer: Supervisor: Address: Telephone: Dates Employed: Reason Terminated:
*  1. Title Supervisor Employer Description
Phone Address Start date End date
  2. Title Supervisor Employer Description
Phone Address Start date End date
  3. Title Supervisor Employer Description
Phone Address Start date End date
  4. Title Supervisor Employer Description
Phone Address Start date End date
  5. Title Supervisor Employer Description
Phone Address Start date End date
PLEASE LIST A MINIMUM OF 5 REFERENCES THAT ARE CHILD CARE OR INDUSTRY RELATED:
(people that have seen you with children or in your industry that can attest to your skill. NOT RELATED IF POSSIBLE i.e.; co-worker, client, someone in your same industry)
* Name:  * Phone: Relationship to Reference:
Name:     Phone: Relationship to Reference:
Name:     Phone: Relationship to Reference:
Name:     Phone: Relationship to Reference:
Name:     Phone: Relationship to Reference:
LIST HERE A MINIMUM OF 5 PERSONAL REFERENCES NOT RELATED, WHO HAVE KNOWN YOU FOR 6 TO 10 YEARS, AND NOT THE SAME AS YOUR CHILD CARE/INDUSTRY RELATED REFERENCES; (i.e.; friends, neighbors, teachers). Include phone numbers where they can be reached during 9:00am - 5:00pm Monday - Friday.
* Name:  * Phone: Relationship to Reference:
Name:     Phone: Relationship to Reference:
Name:     Phone: Relationship to Reference:
Name:     Phone: Relationship to Reference:
Name:     Phone: Relationship to Reference:
*  Please write about yourself; size of your family, where you grew up,
your personality type, why you want to become a Nanny/Provider, and what your goals are for the next 5 years.
( type as much text as you would like )
* Born where?
* Grew up where and how many years there?
* How long at your present address?
* Where are your parents now?
* What have your parents done for employment ?
* What do your parents do for employment ?
* Tell us about your home life, was it good?
* How did your family spend free time?
How many brothers do you have? How old are they?
How many sisters do you have? How old are they?
What are they doing now (school, etc.)?
* Do you have a significant other and what does he or she do for employment?
* What kind of values did your parents instill in you growing up?
* Describe your personality to someone who doesn't know you?
* Can you make a years commitment?
* Describe the ideal situation for your employment.
 How old are the children that have been in your care?
 Please tell us what kinds of activities you like to do with children?
* What qualifications do you feel you can offer a position?
* Describe the speciality that you offer in your field of work. Example: what type of food you prepare, what type of grounds work, etc...
PLEASE LIST ALL OF YOUR ADDRESSES FOR THE PAST SEVEN YEARS,
Beginning with present address & working back. (include street, city, country and state)
* I attest, under penalty of perjury, that I am (click on correct option):
1. A citizen or national of the United States.
2. An alien lawfully admitted for permanent residence. (Alien Number A).
3. An alien authorized by the Immigration and Naturalization Service to work in the United states. (Alien Number A or admission number)
Expiration of employment authorization, if any   .
I attest, under penalty of perjury, the documents that I have presented as evidence of identity and employment eligibility are genuine and relate to me. I am aware that federal law provides for imprisonment and/or fine for any false statements or use of false documents in connection with this certificate.

.

I certify that the facts contained in this application are true and complete to the best of my knowledge. I authorize investigation of all statements contained herein and the references listed above to give any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I further authorize you to provide this form or any information contained on this form, to any prospective employer using the service of this agency.
* By Checking the box below you agree to the above terms.


Click Here for the Nanny Agreement

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