Family Helpers, Inc. - Employment Application

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Employment Application

Fill out the form below. The results will be sent to Family Helpers, Inc.


Name
Address 1
Address 2
Address 3
City
State
Zip/Postal code
Country
Phone Numbers	Day Evening
E-mail
What position are you seeking? Live-in Live-out Who were you referred by? Are you a citizen or have proof of eligibility to work in the US? Yes No Are you able to commit to one year employment? Yes No If no, are you applying for a summer position? Yes No Have you ever been convicted of a crime? Yes No If yes to above, explain: Recent Employment History Please list the last 2 jobs you held. Give a brief description of job duties.

Dates (from - to)
Employer Name
Phone # (with area code)
Supervisor's Name
Describe job duties:
Dates (from - to)
Employer Name
Phone # (with area code)
Supervisor's Name
Describe job duties:

May we contact your previous employers? Yes No How many years worth of child care experience do you have?
Which of the following would you be willing to do?
Light Housework	Yes No
Heavy Housework	Yes No
Children's Laundry	Yes No
Family Laundry	Yes No
Children's Cooking	Yes No
Family Cooking	Yes No

Do you speak fluent English? Yes No
Can you swim?	Yes No
Can you work in a home with pets? Yes No
If yes, would you help care for pets? Yes No

Health
Do you smoke?	Yes No
Do you drink alcohol? Yes No
If yes, how much do you consume?
Do you use recreational drugs? Yes No
Do you have health insurance? Yes No Do you expect it to be provided? Yes No
Are you on any medication? Yes No If yes, please explain.
Do you have any allergies? Yes No If yes, please explain.
Are you able to lift up to 30 lbs.? Yes No If no, please explain.
Do you suffer from any conditions that would impair your ability to work? Yes No If yes, please explain.
Would you consent to getting a physical exam with drug screening before beginning work? Yes No
Date of your last physical exam.
Date of most recent TB exam. Results Positive Negative

Driving Record
Do you drive?	Yes No
How long have you been driving?
Has your license ever been suspended or revoked? Yes No If yes, please explain.
Have you had a traffic ticket in the past 5 years (not parking tickets)? Yes No If yes, please explain.
Have you been driving a car that has been in an accident? Yes No If yes, please explain.
Do you have a car that you can use to get to work? (local candidates only) Yes No

Education
Education level
Do you have any special nanny training or education? Yes No If yes, please describe.

Is there anything you would like to tell us about yourself that would convey your experience and qualifications? (Please include reasons for wanting to be a nanny, work experience, areas of expertise, etc.).