Name

First Name

Last Name

Date

YYYY

Work Phone

(###)

###

####

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Place of Birth

D.O.B

YYYY

Social Security Number

Drivers License Number

State:

Expiration Date:

YYYY

Are you a U.S. Citizen?

Maiden or other name, middle name

Questions

Explain your childcare experience and why you enjoy being a nanny

What are your hobbies and areas of interest?

How do you describe your personality

Driving/Personal Habits:

List all accidents and moving violations in which you were a driver in the last three (3) years:

Have you ever been convicted of a felony?

If yes, please explain:

Do you have your own transportation?

Describe:

If a family requires some driving, are you available for that?

Do you smoke?

Do you take drugs?

Do you drink alcoholic beverages?

Dietary Restrictions:

Activity Restrictions:

Childcare Experience:

Live- In Nanny:

Yes

Live-out Nanny:

Yes

Please describe your experience as a nanny or babysitter:

Have you Ever:

Cared for a nursing baby?

Yes

Prepared formula?

Yes

Given solids to baby?

Yes

Provided 24 hour childcare?

yes

Given medications?

yes

Helped toilet train a toddler?

yes

Taught a child to swim?

Yes

Cared for ill children?

yes

Any experience with special needs children?

If yes, please explain:

Student Teaching:

Teaching:

Camp Counselor:

Babysitting:

CPR Certification:

Child Care courses:

* I will need a copy of CPR card if you have one*

Brought up own children?

yes

Other:

yes

Amount of Experience with:

Newborns:

6-24 mo's:

2-5 yrs:

6-12 yrs:

Teenagers:

What ages do you prefer to work with?

Where did you hear about The Nanny Network?

What salary are you looking for?

What hours/days can you work?

How many hours per week would you like to work?

Do you wish to work in:

Shreveport/Bossier Area

Shreveport only

Bossier Only

Are you available to commit to work for a family for 12 months?

Education/ Interest:

Highest level of education:

High School/Diploma:

Do you swim? How Well?

Do you like pets?

Would you work for a family with inside pets?

Housekeeping:

Would you do general housekeeping?

Children Only

Cooking ability?

light housekeeping only?

Would you consider full housekeeping for extra money?

yes

Past Employment

Please list your past 5 years of employment, including company or family name, dates worked, reason for leaving, supervisor, & telephone number. (attach resume if you have one)

Personal References

Please provide 3 personal reference who have known you for at least 3 years. No relatives please

1) Name

First Name

Last Name

Relationship

First Name

Last Name

2) Phone

(###)

###

####

Name

First Name

Last Name

Relationship:

First Name

Last Name

Phone

(###)

###

####

3) Name

First Name

Last Name

Relationship:

First Name

Last Name

Phone

(###)

###

####

Childcare References:

Please list 5 childcare references that are not relatives within the past 5 years

1) Name

First Name

Last Name

Phone

(###)

###

####

2) Name

First Name

Last Name

Phone

(###)

###

####

3) Name

First Name

Last Name

Phone

(###)

###

####

4) Name

First Name

Last Name

Phone

(###)

###

####

5) Name

First Name

Last Name

Phone

(###)

###

####

Permanent Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Permanent Phone

(###)

###

####

Last Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorization:

By signing below, you authorize that The Nanny Network has my permission to obtain a reference check, which my include information as to my character, general reputation, education, personal characteristics, driving record, police record, and past employment. I hereby authorize you to obtain such reports. I acknoledge that I have read and understand this statement and all statements made, and the information provided all the employment application, of which this is a part, are true to the best of my knowledge. I hereby release and hold harmless The Nanny Network, it's managers, members, directors, agents, assigns, and employees from all liability that arises from my placement and/or employment as a nanny. I also hereby release, hold harmless, and indemnify The Nanny Network from all liability that arises from my placement, and/or employment as a Nanny, including, but not limited to, any civil action brought against me for any act or omission that gives arise to civil liability.

Appliciant's Signature:

Date

YYYY

The Nanny Network 318-841-6266 Sitters' Registry 318-674-7488

The Nanny Network 318-841-6266 Sitters' Registry 318-674-7488

Nanny Network Application

The Nanny Network 318-841-6266 Sitters' Registry 318-674-7488

The Nanny Network 318-841-6266 Sitters' Registry 318-674-7488