Online Family Application

Type Of Nanny

Anticipated Start Date of Nanny:

/ /

Desired Length of Stay for Nanny

/ /

Date of Application

/ /

Name

Spouses Name

Address

City

State

Zip

Email Address

Home Phone

Work Phone

Fax #

Your Occupation

Spouses Occupation

Would you prefer Portfolios

Nanny’s Anticipated Work Schedule

Monday (hrs to work)

Tuesday (hrs to work)

Wednesday (hrs to work)

Thursday (hrs to work)

Friday (hrs to work)

Saturday (hrs to work)

Sunday (hrs to work)

Total Hours

Will there be frequent overtime?

Yes
No

CHILDREN INFORMATION SECTION

Name

Age

Sex

Birthdate

/ /

School?

Yes
No

Hours

Name

Age

Sex

Birthdate

/ /

School?

Yes
No

Hours

Name

Age

Sex

Birthdate

School?

Yes
No

Hours

Name

Age

Sex

Birthdate

/ /

School?

Yes
No

Hours

Is A new Child Expected?

Yes
No

If Yes, 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.)

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, please 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?

THE FOLLOWING INFORMATION IS 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.

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

Yes
No

Signature