Nanny Profile Sign-Up Form


Available Start Date:  
Full Time: Part Time:
Duration: 		Live In: Live Out:
Name of Applicant:
Maiden Name:  
Date of Birth:  
Home Street Address:
City: State:
Zip:  
Previous address if less than 2 years:
Home phone number: Cell Phone:
Email Address: Marital Status:
Number of Children: Ages:
Do you have a valid driver's license? Date issued?
Number of accidents/moving violations in the last 5 years?
Driver's License:
Citizenship:
Citizen of the United States: Social Security No.:
If no, please explain and provide tax payer number:
Background Information:
Have you ever been convicted of a crime?
Date:  
If yes, please explain:
Automobile Information:
Do you have a reliable car?
Do you have car insurance?
Make, Model and Year of car:
Plate No.:
Are you willing to use your car on the job?
Do you expect to be compensated?
Do you need a vehicle provided by the family for use on the job?
Are you willing to drive children to appointments?
Days and Times you are available to work:
Day of the Week
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Overnights
Comments:
Education:
High School: City: Graduated:
Studies:  
College: City: Graduated:
Studies:  
Additional Education:
Languages:
Additional Skills / Experience:
CPR Expiration Date:
First Aid Expiration Date:
Lifeguard Expiration Date:
Childcare courses Expiration Date:
Camp Counselor Explain:
Other Explain:
Child Care Experiences:
Dates Employer Name & Address Phone Number
Age of children:
Duties:
Reason for leaving:
Can we contact his employer?
Dates Employer Name & Address Phone Number
Age of children:
Duties:
Reason for leaving:
Can we contact his employer?
Dates Employer Name & Address Phone Number
Age of children:
Duties:
Reason for leaving:
Can we contact his employer?
Dates Employer Name & Address Phone Number
Age of children:
Duties:
Reason for leaving:
Can we contact his employer?
References: List at least three
Name City / State Phone Relationship
Religion
Personal Interest / Extracurricular Activities: (sports, music, etc.)
Do you like pets?
Any allergies to animals?
How would you describe your energy level?
What duties do you enjoy most?
What duties would you prefer not doing?
Why do you feel confident taking care of children?
What aspect of childcare has been most rewarding to you?
What is important to you when choosing a family to work for?
What age of children do you feel most confident with:
Do you swim?
Do you smoke?
Will you prepare meals for children?
Will you do light housekeeping?
Medical Information:
Are you currently taking any type of medications?
Describe:
Is there any reason why you would NOT be able to lift, bend or care for a child and/or their needs: (back problems, unable to drive etc..)
Explain: (if none indicate "none at this time"
Any other medical conditions not mentioned:
Compensation Information:
Paid by the hour: Would like hourly
This is what I want to end up with per hour, after taxes
Paid Salary: Would like per week for hours
This is what I want to end up with per hour, after taxes
Paid holidays required?
Health Insurance required?
Vacation required paid?
Time off: When the family advises you that your service is not required on a given day do you expect to be paid for the day?
A Background check will be charged to applicant in the amount of $45.00 for processing - upon offer of position. Please Initial:
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These two documents need to be downloaded and filled out. Please bring the completed forms when you come for your interview. Application Agreement Backtrack

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Family Care Solutions
233 South Main Street, Plymouth, MI 48170
Phone: (734) 459-6930 | Fax: (734) 459-2091
Email: info@family-care-solutions.com