Family Information

Family Care Needs

Number of Babies: Single Twins Triplets
Estimated Arrival Date of Newborns:
Gender: Male Female Unknown
Length of Employment: 1–6 weeks 7-12 weeks 13 weeks and beyond
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

Weekly Schedule


Describe NCS job duties & responsibilities:

Will the NCS have non-childcare related housekeeping responsibilities? 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 NCS:

NCS Benefits

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

Other NCS 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?