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Are you looking for



Are you a U.S. citizen? If no, please provide evidence of status.

Are you currently employed? If yes, where? (company name, address, phone)

What high school did you attend?

What college did you attend?

What was your major field of study?

Briefly outline your experience in the following:

Childcare experience

Housekeeping experience

Will you do light housekeeping?

Will you cook for the children?

Please provide complete details of your work experience. Start with your latest position and go back from there. If there are any gaps in employment, please explain why.

Please list 3 or more references. At least one must relate to recent childcare work.
Name, Address, Phone No., Relationship to you:

Have you ever been convicted of a crime? If yes, please explain why.

Do you have a valid driver's license?

Driver's license # and state

Are you allergic to any animals? If yes, which animals?

Would you work in a home with pets?

Do you swim? If yes, how well?

Do you smoke? If yes, how much and can you agree to not smoke on the job?

Do you drink alcohol? If yes, how often?

Are you taking any medication that interferes with your mental/physical functions? If yes, please explain.

Is there any special area of town you want to work in?

Would you be willing to commit to a nanny position for at least one year?

How many hours a week would you like to work?

What age child do you feel most comfortable with?

How many children are you comfortable caring for at one time?

Briefly describe the worst childcare situation you have ever been in and how you handled it:

What are your strengths?

What are your weaknesses?

What are your hobbies?

Please add any additional information you would like to tell us about yourself:

Signature of Applicant:


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Full Name Email Phone Number