Family Information

Children's Information

1st Child

Male Female

2nd Child

Male Female

3rd Child

Male Female

4th Child

Male Female

Family Care Needs

Type of Employment: Full-time (30+ hours) Part-time (30 hours or less)
Length of Employment: Permanent Temporary
Type of Provider: Live-In Live-Out Either

Live-In Accommodations (if applicable): Please check all that apply

Private Bedroom Private Bathroom Private Entrance Basement Apartment In-law Apartment

Desired Start date for Nanny

Weekly Schedule


Describe Nanny job duties & responsibilities:

Will the Nanny have non-childcare related housekeeping responsibilities? Yes No
Will the Nanny be driving the Children? Yes No
Will you provide a car for the Nanny’s on duty use? Yes No
Do you have a swimming pool? Yes No
Do you have any pets? Yes No
Does anyone in your family smoke? Yes No

List 3 qualities that are most important to you when choosing the right Nanny:

Nanny Benefits

What is the gross salary range for your position (before taxes)?

Other Nanny Benefits (Please check all that apply):

Paid Vacation Partial Contributions to Health Insurance Full Health Insurance Paid Sick Days Paid Personal Days Bonuses Mileage/gas reimbursement Other

How did you hear about us?