Nanny Employment Application
Please print legibly
Personal Information
Last Name
First Name
Middle Initial
Full Street (Mailing) Address (including apartment number)
City
Date
State
ZIP
Social Security Number
Day Telephone
Evening Telephone
Fax Number (if available)
Available starting date
Hours available to work
Days available to work
Desired salary range
18 years of age or older?
Do you smoke?
If no, do you object to smoking?
Are you legally eligible to work in the U.S.?
Yes No
Yes No
Yes No
Yes No
Do you have a drivers license?
Since When?
List state and license number
Yes No
Have you ever had a moving or driving related violation or traffic accident (include tickets)?
Yes No
If yes, list specifics.
Yes No
Have you ever been arrested or convicted of a felony and/or a misdemeanor?
If yes, please explain.
Yes No
Have you ever been the subject of a substantiated complaint of child or sexual abuse?
If yes, please explain.
Are you certified in First Aid?
Are you certified in CPR?
Do you swim?
Are you certified in lifesaving?
Yes No
Yes No
Yes No
Yes No
Yes No
Are you willing to become certified in these programs?
If no, please list which programs you are NOT willing to become certified in
Are you comfortable caring for children when they are mildly ill?
Do you need health insurance?
Yes No
Yes No
Please list any pets you would NOT be comfortable being around/living with.
For Live-in Applicants only
Have you ever lived away from home before?
If yes, how far away (in hours or miles), for how long and when?
Yes No
Have you ever been responsible for the payment of your own living expenses?
Yes No
Have you ever had a checking account?
Do you do your own laundry?
Yes No
Do you plan on bringing a vehicle?
Do you have cooking skills?
Yes No
Yes No
If yes, please list year, make and model
Yes No
Copyright 2000-2012 HomeWork Solutions Inc.
All rights reserved
Medical Information
Yes No
Do you have any medical condition that could affect your ability to care for children?
If yes, please explain.
For each of the following, please indicate if you are willing to submit to, at no expense to you.
Physical Examination
Drug screening
T.B. test
HIV test
Yes No
Yes No
Yes No
Yes No
Yes No
Have you been immunized against the common childhood diseases?
If no, which ones have you NOT been immunized against?
Yes No
Do you have any diet restrictions?
If yes, please explain
Yes No
Do you have any current or history of emotional health problems?
If yes, please explain
Have you ever been recommended to an alcohol or drug rehabilitation or mental institution?
Yes No
If yes, please explain
Educational Background
Do you have a high school diploma/GED?
Please list name of high school
Yes No
Please list name of college (if attended)
Dates attended
Degree/Certificate Received
Phone Number
Major
Please list any other special training you would like us to be aware of
Employment History
Current Employer (if a company, full company name)
Supervisor's Name / Phone Number (if different)
Employer's full mailing address
City
Employer's Telephone Number
Position you held
Employed since
Reason for Leaving
State
ZIP
Ending salary
May we contact?
Yes No
Copyright 2000-2012 HomeWork Solutions Inc.
All rights reserved
List ALL CHILDCARE References for the Past FIVE Years
Company/Family Name
Date Employed From
To
Employer's full mailing address
City
ZIP
Employer's Telephone Number
Position you held
State
Ending salary
May we contact?
Yes No
Reason for leaving
Describe your responsibilities in detail
Company/Family Name
Date Employed From
To
Employer's full mailing address
City
ZIP
Employer's Telephone Number
Position you held
State
Ending salary
May we contact?
Yes No
Reason for leaving
Describe your responsibilities in detail
Company/Family Name
Date Employed From
To
Employer's full mailing address
City
ZIP
Employer's Telephone Number
Position you held
State
Ending salary
May we contact?
Yes No
Reason for leaving
Describe your responsibilities in detail
Company/Family Name
Date Employed From
To
Employer's full mailing address
City
ZIP
Employer's Telephone Number
Position you held
Ending salary
State
May we contact?
Yes No
Reason for leaving
Describe your responsibilities in detail
Copyright 2000-2012 HomeWork Solutions Inc.
All rights reserved
Personal, Character or Professional References
PERSONAL, CHARACTER OR PROFESSIONAL REFERENCE 1
Name
Relationship
Phone Number
Length of time known
PERSONAL, CHARACTER OR PROFESSIONAL REFERENCE 2
Name
Relationship
Phone Number
Length of time known
Childcare Background/Information
Ages of The Children You Have Cared For
Youngest
Oldest
Please List The Ages You Have the Most and Least Experience With
Most
Least
Age you started caring for children
Did you care for your siblings?
Yes No
Yes No
Have you had experience working with special needs children?
If yes, please explain
Yes No
Have you had to handle an emergency of any kind?
If yes, please explain
I CERTIFY THAT I HAVE ANSWERED ALL THE QUESTIONS ON THIS APPLICATION
ACCURATELY AND TO THE BEST OF MY KNOWLEDGE. I HAVE NOT WITHHELD ANY
INFORMATION WHICH WOULD CAUSE THE INFORMATION GIVEN ABOVE TO BE
MISLEADING. IN THE EVENT OF MY EMPLOYMENT AS A RESULT, IN FULL OR IN
PART, FROM THE INFORMATION CONTAINED ON THIS APPLICATION, I
UNDERSTAND THAT ANY INACCURATE OR MISLEADING INFORMATION IS
GROUNDS FOR IMMEDIATE TERMINATION OF EMPLOYMENT.
_______________________________
Signature of Applicant
________________________
Date
Copyright 2000-2012 HomeWork Solutions Inc.
All rights reserved
