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Today's Date
First Name Middle Name Last Name
Maiden Name Birth Date: Month: -select- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day: -select- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: -select- 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 Soc. Sec. #
Texas Driver’s License Number Out-of-state Driver's License Number State -select- AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY
Home Phone: Work Phone: Mobile Phone:
Best Time To Call: A.M. P.M.
Email Address:
Home Address: City: State -select- AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY Zip:
How long have you lived there?
Please list any previous addresses :
When are you available to start?
Can you commit to one year or more? Yes No
Desired working position/s Mark all that apply: Full-time Part-time Summer Live-in Live-out Temporary/On Call
Describe your desired schedule
Can you work weekends? Yes No Can you travel with a family?Yes No
Salary Requirements Benefit Requirements
Do you have health insurance? Yes No Would you take a routine physical and/ or drug test? Yes No
Are you able to carry a child under five years old (up to 60lbs)? Yes No
Do you have any allergies, special diet or medication needs? Yes No If yes, provide details
Have you ever had, or do you have, a problem with alcohol or drug abuse? Yes No
Do you have any hearing or visual impairment that may limit your ability to care for children? Yes No If yes, provide details
Do you have or plan to get any tattoos or piercings? Yes No If yes, provide details Have you ever been convicted of a felony or misdemeanor? Yes No Do you have any charges pending? Yes No
Do you have permanent legal status to work in the US? Yes No
Do you have your own vehicle? Yes No Year, make, and model
How long have you been driving? Do you have auto insurance? Yes No
Have you ever been the driver in a car accident or charged with a moving violation? Yes No If yes, provide details
Do you feel comfortable with children in your car? Yes No How did you hear about our agency?
Please Note: In our effort to protect your privacy, only the following numbered (1-25) questions will be sent to our clients. The rest of your pertinent information is consolidated into a “profile”, so as not to reveal sensitive information such as your driver’s license and social security number. Any references letters, formal resumes or certificates will also be included in the profile.
1. What ages and gender of children do you prefer to work with?
2. Are you comfortable work for a parent who works at home, is single or is a stay-at-home parent? Yes No If not, explain
3. Will you work with pets? Yes No
4. Do you have training for disabilities? Yes No If yes, provide detail
5. Do you have any experience working with newborns or multiples? Yes No If yes, provide detail
6. Are you CPR, first aid or lifeguard certified? Yes No If yes, provide detail
7. Do you smoke? Yes No
8. What languages do you speak fluently ?
9. Do you have any musical ability? Yes No If yes, provide detail
10. What are your hobbies and interests?
11. Do you play any sports or participate in any other physical activities? Yes No If yes, provide detail
12. Do you know how to swim? Yes No If yes, provide detail
13. What is your policy on discipline?
14. What are your plans for the future?
15. Please list your education, beginning with high school. Include name of school, location and date graduated, noting any course pertaining to childcare
16. May we provide your contact information to other nannies for purpose of networking? Yes No
18. What do you hope to gain from your career as a nanny?
19. What, if anything would you change about yourself?
20. What do you feel is your best asset?
21. Describe your childhood
22. The six month old you are caring for hates having her diaper changed, and starts screaming as soon as you lay her on the changing table. What would you do?
23. The 16 month old boy in your care is playing with the dirt in a potted plant. What would you do?
24. The 3 year old in your care keeps throwing a ball at his younger sibling. What would you do?
25. The 10 year old in your care is throwing a fit because she wants to go over to a friend’s but she’s supposed to finish her homework first. What would you do? _________________________________________________________________________________________________________
Starting with your current position, please list your last four places of employment. Include addresses, phone numbers, name of contact person, hours, pay, benefits, position held and duties. 1. 2. 3. 4.
Please list four people (not family) whom we may call for childcare references. Please include their phone number and relationship to you. 1 2
3
4
Please list two people (not family) who have known you for at least five years, whom we may contact as character references. Please include their phone number and relationship to you. 1
2
THIS AGREEMENT (“Agreement “) is made this day of ,20 by and between (“Applicant”) and Nanny Works. In consideration of Nanny Works acceptance of Applicant’s application and other good and valuable consideration, the receipt and sufficiency of which is acknowledged by the parties, it is hereby agreed as follows: Applicant understands and acknowledges that Nanny Works contracts with families in the the area who pay fees in return for Nanny Works helping them locate a nanny. Applicant further understands and acknowledges that submitting a Nanny Application with Nanny Works authorizes Nanny Works to provide interested families with complete information regarding applicant’s background, education, and ability to perform essential functions of a nanny position. Applicant certifies that the information provided in and with applicant’s Nanny Application to Nanny Works, is true, accurate, and correct. Applicant gives Nanny Works, and it’s agents, permission to investigate and verify the information provided on their Nanny Application submitted to Nanny Works. Applicant further agree to cover, defend and hold Nanny Works and its agents and members harmless from any and all damage, loss, liability, and expenses, including reasonable attorney fees, arising out of any incorrect, fraudulent or dishonest information contained in applicant’s Nanny Application. Applicant understands and acknowledges that Nanny Works cannot guarantee that the will be employed by a family as a nanny. Nanny Works has no obligation to locate a nanny position for applicant, and may, in its sole discretion, remove applicant from its applicant list at any time without notice.
Applicant agrees not to accept employment with any family referred through Nanny Works within one (1) year of the referral, whether employment is offered on a full-time, part-time, or summer basis, unless the family has first paid the required Service Fees to Nanny Works pursuant to the family’s contract with Nanny Works.
Applicant further covenants and agrees to refrain, directly or indirectly whether individually or as a partner, officer, director, agent, lender advisor, investor, principal, consultant, shareholder, member or otherwise, from owning managing, operating or controlling, under any circumstances, and under any conditions whatsoever, any enterprise engages on a business activity, directly or indirectly, competing with Nanny Works within a 60 miles radius of Nanny Works offices for a period of two (2) years immediately following Applicant’s submission of Nanny Application to Nanny Works.
Applicant understands and acknowledges that they are responsible for screening employment offers made by families, negotiating and documenting the terms and conditions of their employment, verifying information from families and deciding whether they will accept employment with a family. Nanny Works may provide applicant with information about available positions and applicant understands and acknowledges that Nanny Works cannot guarantee the truth or accuracy of the information about the positions.
Applicant releases and discharges Nanny Works of and from any and all damages, loss, liability or expense; whether now known or unknown, arising out of any act or omission of a family that the applicant enters into an employment agreement with whether negligent, intentional or fraudulent.
Applicant further understands and acknowledges that full responsibility for payment of and compliance with Social Security, Worker’s Compensation and other taxes, similar laws and regulations related to applicant’s employment rest with the employer and applicant. Applicant understands and acknowledges that Nanny Work s only works with applicants who are ages 18 or older and who can legally work on a permanent basis in the United States. Applicant recognizes that irreparable injury may result to Nanny Work s and its business in the event of a breech by Applicant of the restrictions imposed in this Agreement and that Applicant’s acceptance of such restrictions was a material factor in Nanny Works decision to accept Applicant’s Nanny Application. In the event Applicant shall engage in any acts of violation of this Agreement, Nanny Works shall be entitled, in addition to such other remedies and damages as may be available to it, to a temporary restraining order or preliminary injunction prohibiting Applicant from engaging in any such acts, as well as the recovery of reasonable attorneys fee. If Nanny Works seeks such temporary restraining order or preliminary injunction, Nanny Works shall not be required to post any bond with respect thereto. Applicant understands and acknowledges that they are not an employee, agency, or independent contractor of Nanny Work s and nothing contained in this Applicant Agreement shall be deemed to create such a relationship.
IN WITNESS WHEREOF, the parties have executed this Agreement as of the day and year first above written.
APPLICANT: Enter your name here to indicate that you have read and agree to all the above When you are called in for the personal interview you will be asked to sign a printed copy of the above agreement.