Full-Time, Live-In
Full-Time, Live-Out
Part-Time
Latch-Key, After School
Summer

Parent Information:

Full Name(s):


Address:

Phone:

Father's Employer, Work Address, Work Phone:

Father's Social Security Number:

Father's Age:

Mother's Employer, Work Address, Work Phone:

Mother's Social Security Number:

Mother's Age:

Do both parents reside at home?
Yes No
If, no, please state why:

Child Information:

Child's Name:

Boy Girl Age Grade Special Needs Yes No

Boy Girl Age Grade Special Needs Yes No

Boy Girl Age Grade Special Needs Yes No

Boy Girl Age Grade Special Needs Yes No
If any child has special needs, please provide details here:

Other Family Information:

Number and types of pets:

Any language other than English spoken at home? Yes No
If yes, what language
and must your nanny speak that language? Yes No

Do you observe any religious dietary laws or have dietary restrictions in your home?
Yes No

Do you employ domestic help, such as a maid or cleaning service? Yes No

Have you, or any member of your immediate family (including ex-spouses, if applicable)
been arrested or convicted of any offense other than a minor traffic violation?
Yes No
If yes, please gives dates and other details:

Are there any possible risks to the health and safety of the nanny inherent in this position?
Yes No
If yes, please explain

Will the family accept responsibility for taking reasonable care to protect the nanny
from physical, sexual, emotional, or psychological abuse by family members and/or guests?
Yes No

Are there any unusual lifestyle patterns which would require open disclosure to
CARING NANNIES and/or the nanny prior to the nanny working for your family? (i.e. marital
problems, drug use, emotional, financial, criminal or civil problems with which the family is
coping)

Please name two references (name, address, phone) who could speak on behalf
of your family's character and who will submit letters of recommendation if necessary.

SCHEDULING:

When would you like the nanny to start work?

What days and hours will the nanny work and what days will the nanny have off?
Sunday
Hours

Monday
Hours

Tuesday
Hours

Wednesday
Hours

Thursday
Hours

Friday
Hours

Saturday
Hours

Please select the accomodations you will provide if you have a LIVE-IN nanny:
Separate QuartersPrivate Bedroom & BathroomPrivate Bedroom & Semi-Private Bath

Transportation:

Will you be providing the nanny with a car? Yes No
If yes, will the nanny be covered under your car insurance? Yes No
If no, would you reimburse the nanny 30 cents/mile for gas used in the nanny's car
for family business? Yes No

Will you need the nanny to travel with you? Yes No
If yes, where and how often:

General Information About the Nanny:

Do you prefer a female or male nanny? FemaleMaleDoesn't Matter

Must the nanny possess a valid driver's license? Yes No

What type of personality would you like the nanny to have?

Do you prefer a non-smoker? YesNoDoesn't Matter
Is smoking permitted off-duty? Yes No

Job Description:

What household tasks would you like the nanny to take care of:

Other:

What abilities and skills do you desire the nanny to have?

Please describe any unusual requirements you may have.
Include any special needs your child(ren) require(s)?

Please state the salary range you are willing to pay?

What are your family's interests and activities?

Where did you hear about CARING NANNIES?

I/WE fully understand and accept that misdescription or misrepresentation of hours, duties,
or any other aspect of the employment situation herein, or nonpayment of any fees, will, at the
sole discretion of CARING NANNES, make the CARING NANNIES FAMILY AGREEMENT
null and void and will require that CARING NANNIES take immediate action. I/WE acknowledge
receipt of the FAMILY AGREEMENT and agree to its terms and conditions. I/WE also understand
that the registration fee is non-refundable.

Signature of Parent: Date:
Signature of Parent: Date:
Email Address: