Family Information  How did you hear about us?

Names:

Address:

City: St: Zip:

Home Phone: Cell Phone:

Business Phone:  Fax Number:

Email Address:

Family Structure: ex: Married, both work full time  

Child 1: Name: DOB: Age:

Child 2: Name: DOB: Age:

Child 3: Name: DOB: Age:

Child 4: Name: DOB: Age:

Are you planning on having more children? Yes No If so, When?

Do you have any household Animals? If so, Please list:

Will the nanny be required to provide care for these animals? Please explain:

Do any of your children have Special Needs?  Explain

Do any of the children have allergies?

Do any of the children take medications? If so, please explain:

Nanny Information

Age preference:  Gender: Female   Male   Either

Level of Education Preferred?

We are seeking a Live In Nanny  Live Out Nanny 

Time frame: Temp (less than 6 mo.)  Short Term (1 yr)   Long Term (2+ yrs)

Hours per week: Part Time (less than 25 hrs)  Full Time (more than 25 hrs)

Please describe the possible schedule:

Will you need a nanny who can travel with you?  Yes   No

How often and to where do you travel?

Describe your ideal Nanny:

Please describe your Nanny's living quarters if you are seeking a Live-In:

Will you be providing a vehicle for your nanny?  Yes  No

If the nanny is required to transport children/run errands in her personal vehicle, will you provide a Gas/Maintenance Allowance?  Yes    No   Unsure

If your nanny will be transporting your children, please describe a typical day/outing:

Would you prefer a nanny who speaks a language other than English? Yes  No   If so, what?

Childcare Related Duties:

Meals for Children      Wash/Dry/Fold Children's Laundry      Basic Clean up after children      Grocery Shop for Children      Help w/Homework      Clean Children's Bathroom      Make Children's Beds

Household Duties expected from your nanny:

Maintain Grocery List      Grocery Shop for Family     Prepare Family Meals  Clean Kitchen: Run/Empty Dishwasher      Dust/Vacuum House      Clean Family Bathrooms      Make Parents Beds     

Other Duties Expected not listed above:

Please tell us any other information you think is relative that we have not asked in this form: