Personal Information

Name

Are you eligible to work in the United States? YesNo

Are you CPR certified? YesNo

If no, are you willing to be certified? YesNo

Are you First Aid Certified? YesNo

If no, are you willing to be first Aid certified? YesNo

Do you smoke? YesNo

Do you have a valid driver’s license? YesNo

Do you have a car? YesNo

If yes, please specify:

Have you had any traffic or driving violations? YesNo

If yes, please explain:

Education

High School

College/University

List any other certification, courses, etc that you may have:

DESIRED POSITION & AVAILABILITY

Desired position; please check all that apply: Part-Time NannyFull-Time Live-In NannyFull-Time Live-Out NannyNewborn Care SpecialistTemporary/Vacation NannyBabysitter

I am experienced with the following ages: please check all that apply: New-Born to 9 months9 months to 24 months2 to 5 years5 to 10 years10+ years old

In what capacity do you have childcare experience, please check all that apply? Private babysittingRelatives Day Care CenterPreschool teacherTeacherChurch NurseryAfter School assistantCamp CounselorTeam CoachTutor Live-In NannyLive out NannyOther

If yes, please explain:

Can you commit to at least a year? YesNo

Date Available to start

Weekly Schedule

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Desired total number of hours per week

EMPLOYMENT HISTORY / REFERENCES

1.

2.

3.

PERSONALITY & BACKGROUND

Do you speak any other language apart from English? YesNo

ADDITIONAL PLACEMENT QUESTIONS

Are you available to travel with a family? YesNo

Comfortable Preparing meals for the family? YesNo

Comfortable assisting with housework? YesNo

Do you swim? YesNo

Are you available for overnights? YesNo

Are you able to relocate? YesNo

As part of our services to our families, we will conduct a criminal background check, motor vehicle report history, a social security trace and a sexual offender’s check. Do you give the agency permission to run these checks? YesNo

Upload child care resume if you have one: