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:
High School
College/University
List any other certification, courses, etc that you may have:
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
Can you commit to at least a year? YesNo
Date Available to start
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
Desired total number of hours per week
1.
2.
3.
Do you speak any other language apart from English? YesNo
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:
