Full Name |
|
Address 1 |
|
Address 2 |
|
City |
|
State |
Zip Code |
Country |
|
Phone Numbers |
Day
Evening |
email |
|
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 felony?
Yes
No
If yes, explain: (The existence of a criminal record is not an absolute bar to employment.)
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 use recreational drugs? |
Yes
No |
| 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 & drug screening?
Yes
No |
| Date
of your last physical exam.
|
|
| 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.
|
Heve you had a traffic ticket in the past 5 years (not parking)?
Yes
No
If yes, please explain.
|
Have you had an accident while driving a car in the past five years?
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 |
|
| Are you CPR certified? |
Yes
No |
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.).
|
|
|
