Family Application

Live-In
Full-Time
Summer
Live-Out
Part-Time

Anticipated Start Date of Nanny:
Desired Length of Stay for Nanny:

Date of Application:

FAMILY INFORMATION

Name:
Spouse’s Name:
Address:
City: State: Zip:
Home Phone:
Work Phone(s):
Fax Number: Email:
Your Occupation:
Spouse’s Occupation
Would you prefer portfolios:
mailed faxed

Nanny’s Anticipated Work Schedule:

Will there be frequent overtime? Yes No

CHILDREN INFORMATION SECTION

Children living in your home

Age Sex Birthdate School Hours

Is a new child expected? Yes No If yes, please indicate estimated birthday:

Please describe each child in your family, giving an idea on temperament, likes, dislikes, etc.

FAMILY RELATED INFORMATION

Please describe your family (things you enjoy doing together, discipline, philosophies, etc.) Feel free to use separate sheet of paper.

Do you have any pets? Yes No If yes, what type?
Is nanny responsible for their care? Yes No

Do you follow any dietary practices to which you would like a nanny to adhere? Yes No If yes, please describe:

Who, in addition to parents and children, lives in the home?


Will you have any household help other than the nanny? If so, describe:

NANNY RELATED INFORMATION

What do you anticipate nanny’s child care responsibilities to be?

What additional responsibilities (such as housekeeping, errands, etc.) would you like your nanny to perform?


Please describe your ideal nanny:

Would you consider a nanny who wanted to bring her child to work with her? Yes No

If you are an at home parent, please describe how much time you and your nanny will be working together, and what you expect her responsibilities to be when you are home:


Will the nanny be required to drive as part of her job? Yes No
If yes, explain:


Is there a car made available to the nanny to use during work hours? Yes No
If yes, manual or automatic? Manual Automatic

If there is no car made available to nanny during work hours, what type of reimbursement will she receive?

INFORMATION FOR LIVE-IN APPLICANTS ONLY

Please describe nanny’s accommodations


Please describe your home and neighborhood:


Are their special home rules? (Such as curfew, having friends over, T.V. restrictions, etc.)


Is board included? Yes No

Will nanny have use of a car for personal outings? Yes No

Which family activities would you like the nanny to be included?


Which family activities would you like to keep separate?

SALARY AND BENEFITS

Expected salary per week
Expected Salary per hour
Overtime rate

What benefits will be offered to the nanny? Please check off all that apply and describe in the space provided.
Health insurance
Paid Holidays
Paid sick days
Vacation
Travel with family
Health club memberships
Other

REFERENCES

We ask that you include two character references for the nanny to call if she wishes to do so. If you’ve had a previous nanny, listing him/her as one would be ideal.

Name:
Relationship:
Address:
Telephone Number:

Name:
Relationship:
Address:
Telephone Number:

Name:
Relationship:
Address:
Telephone Number:

I prefer not to provide any references at this time.

Please check here if you would be willing to pay for CPR certification.

I have read and signed the agreement between Portland Nannies, Inc. and myself and agree to the terms stated throughout it.

Signature Date

How did you hear about Portland Nannies, Inc.?:

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