Live Out Live In
Full Time Part Time Summer/Short Term

Hours Available
Temporary
Weekdays Weeknights Weekends
Overnight

	Please fill in all duties you are willing to do related to care of child(ren):
	Laundry
	Feeding
	Bathing
	Preparing meals
	Reading to children
	Age appropriate activities
Other:
	Please fill in all duties you are willing to do that are not non-child related:
	Housekeeping
	Laundry
	Errands
	Cooking
Other:

Are you trained in Infant/Child CPR?	Yes No
Do you know First Aid?	Yes No
Can you swim?	Yes No
Are you willing to travel?	Yes No
Are you willing to drive the children around?	Yes No
If so, do you have an insured car?	Yes No
Make/Model:
Please describe your driving record:
Have you ever been arrested?	Yes No
If yes, please describe:
Have you ever been convicted of a crime?	Yes No
If yes, please describe:
Would you work in a home with pets?	Yes No
Do you smoke?	Yes No
How would you rate your overall health?

Employment History

Employer:
Phone Number	( ) -
Address
From: To:
Gross Salary: (Before Taxes)
Please describe duties:
Reason for leaving?
Can we contact?	Yes	No

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Employer:
Phone Number	( ) -
Address
From: To:
Gross Salary: (Before Taxes)
Please describe duties:
Reason for leaving?
Can we contact?	Yes	No

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Employer:
Phone Number	( ) -
Address
From: To:
Gross Salary: (Before Taxes)
Please describe duties:
Reason for leaving?
Can we contact?	Yes	No

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Childcare References (These can be the same as your employment history references listed above.)

Same as above?

Family:
Address:
Phone Number:	( ) -
Please describe duties:
Start date: End Date:

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Family:
Address:
Phone Number:	( ) -
Please describe duties:
Start date: End Date:

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Family:
Address:
Phone Number:	( ) -
Please describe duties:
Start date: End Date:

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Questions

Why would you like to be a nanny?

What types of activities do you enjoy doing with children?

Please describe your personality.

What are your hobbies and interests?

What are your future goals?

Please describe your discipline philosophy.

I am happiest when:

A bad day is when:

How did you hear about Nanny Next Door?