Family Application Form

Security Information
When you have finished completing this form, be sure to press the "Submit" button.

Required Fields Are In Blue!
Primary Parent Information
Last Name First Name
Occupation Age
Employer Work Phone
Spouse Information
Last Name First Name
Occupation Age
Employer Work Phone
Home Address
City, State, Zip-Code
Home Telephone Best Time To Call
Family E-mail Address:
Family Fax Number:
Call Prior To Faxing:
Age of Nanny Preferred:
Preference of Nanny's Sex:
Which times are best for you to
meet with prospective candidates:
What is the preferred starting date for the Nanny:
 Year: Month: Day:
In order to better serve your needs,
please indicate your desired length of service for the Nanny:
How did you hear of us?
Specific Questions Regarding Your Situation:


Do you require the nanny to drive?
Will the Nanny have use of car on duty?
Will the Nanny have use of car off duty?
Is it OK for the Nanny to bring a car?
Is it OK if the Nanny Smokes?
Do you have any family pets?
Do you require a FT/PT Nanny:
Do you prefer Live-In or Out:
What is your expected Live-In Pay Range:
What is your expected Live-Out Pay Range:
How many children do you have:
Is it OK for the Nanny to bring his/her own kids?
Will you contribute to the Nanny's Healthcare:
Will you consider paid Vacation/sick days/holidays:
Will you consider quarterly evaluations/merit raise:
I am interested in interviewing ALL nannies who
appear to be appropriate, within the fee range:


When Do You Require a Nanny?

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Hours:
Hours:
Hours:
Hours:
Hours:
Hours:
Hours:


What Qualifications Do You Require From Your Nanny:


Family requires experience at a daycare?
Family requires previous experience as a Nanny?
Family requires 1 year of Child-Care Experience?
Family has Infant Children:
Family has Toddler Children:
Family has Pre-School Children:
Family has School-Aged Children:


If you are uncomfortable submitting the following information via the Internet, you may skip over these questions. You may either print out this application and fax it to us, or you may call our office and supply the information over the telephone.
If you have had either child-care, or household help in the past,
please state what pleased you most, and least about your past experiences:

Please list three references, who are also parents, who will speak on behalf of your character:

Name Street Address City/Zip Phone
Name Street Address City/Zip Phone
Name Street Address City/Zip Phone

If your position requires a live-in Nanny, please describe the accomodations:

Children's Names, Ages and The # of Hours Home During The Day:
Primary parent's work schedule?
Spouse's work schedule?

Comfort Level Factor
As your family starts the search for the most suitable nanny candidate, it is helpful to consider two important questions. Please list as many factors as may apply under each respective question below. While considering these questions you may wish to reflect on experiences with previous nannies, coworkers, employees, and if looking for a live-in nanny, those you have lived with.

1) The following represent personality characteristics, and/or work habits, and/or work and educational experience, own car and drivers license/etc. which are important for the nanny we hire to possess:
2) The following represent personality, or other characteristics and work habits. Driving status/etc., which we would not be comfortable with in the Nanny we hire:

Please read the following carefully prior to clicking on submit

If, at any time within two (2) years after an initial interview between a nanny and a family applicant of the or it's affiliates or servants, the nanny becomes a direct, or indirect short term or long term provider of services to the family, independently, resulting in non-payment of the placement fee or non-compliance with the placement fee policy to the Agency, the family by signing below, agrees to pay to the Agency, a fee of $3000 (Three thousand dollars), which may be processed electronically plus all reasonable legal fees incurred in collecting it.

By submitting this electronic application, I have read and understand the placement fee structure and that there is a placement fee due to the agency at the time that a nanny accepts employment with a family whether long or short term and all fees shall be charged to the clients account when due. I understand that the $150.00 (one hundred and fifty dollars) application fee is a non-refundable fee, required in order to begin the search and screening process, payable prior to meeting with Agency staff and / or candidates.

I also grant permission toAgency or it's Affiliates or servants to talk with the individuals listed as references.

Call us with any questions at (508) 650-8889