Nanny Placement 

 

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Nanny Placement – Family Application
</h2>
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1. Parent #1 First and Last Name
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*
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2. Parent #1 Email Address
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*
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<span class=”phone-separate” aria-hidden=”true”>

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*
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5. Family Address
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*
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<option value=””> Please Select </option>
<option value=”United States”> United States </option>
<option value=”Afghanistan”> Afghanistan </option>
<option value=”Albania”> Albania </option>
<option value=”Algeria”> Algeria </option>
<option value=”American Samoa”> American Samoa </option>
<option value=”Andorra”> Andorra </option>
<option value=”Angola”> Angola </option>
<option value=”Anguilla”> Anguilla </option>
<option value=”Antigua and Barbuda”> Antigua and Barbuda </option>
<option value=”Argentina”> Argentina </option>
<option value=”Armenia”> Armenia </option>
<option value=”Aruba”> Aruba </option>
<option value=”Australia”> Australia </option>
<option value=”Austria”> Austria </option>
<option value=”Azerbaijan”> Azerbaijan </option>
<option value=”The Bahamas”> The Bahamas </option>
<option value=”Bahrain”> Bahrain </option>
<option value=”Bangladesh”> Bangladesh </option>
<option value=”Barbados”> Barbados </option>
<option value=”Belarus”> Belarus </option>
<option value=”Belgium”> Belgium </option>
<option value=”Belize”> Belize </option>
<option value=”Benin”> Benin </option>
<option value=”Bermuda”> Bermuda </option>
<option value=”Bhutan”> Bhutan </option>
<option value=”Bolivia”> Bolivia </option>
<option value=”Bosnia and Herzegovina”> Bosnia and Herzegovina </option>
<option value=”Botswana”> Botswana </option>
<option value=”Brazil”> Brazil </option>
<option value=”Brunei”> Brunei </option>
<option value=”Bulgaria”> Bulgaria </option>
<option value=”Burkina Faso”> Burkina Faso </option>
<option value=”Burundi”> Burundi </option>
<option value=”Cambodia”> Cambodia </option>
<option value=”Cameroon”> Cameroon </option>
<option value=”Canada”> Canada </option>
<option value=”Cape Verde”> Cape Verde </option>
<option value=”Cayman Islands”> Cayman Islands </option>
<option value=”Central African Republic”> Central African Republic </option>
<option value=”Chad”> Chad </option>
<option value=”Chile”> Chile </option>
<option value=”China”> China </option>
<option value=”Christmas Island”> Christmas Island </option>
<option value=”Cocos (Keeling) Islands”> Cocos (Keeling) Islands </option>
<option value=”Colombia”> Colombia </option>
<option value=”Comoros”> Comoros </option>
<option value=”Congo”> Congo </option>
<option value=”Cook Islands”> Cook Islands </option>
<option value=”Costa Rica”> Costa Rica </option>
<option value=”Cote d&#x27;Ivoire”> Cote d&#x27;Ivoire </option>
<option value=”Croatia”> Croatia </option>
<option value=”Cuba”> Cuba </option>
<option value=”Cyprus”> Cyprus </option>
<option value=”Czech Republic”> Czech Republic </option>
<option value=”Democratic Republic of the Congo”> Democratic Republic of the Congo </option>
<option value=”Denmark”> Denmark </option>
<option value=”Djibouti”> Djibouti </option>
<option value=”Dominica”> Dominica </option>
<option value=”Dominican Republic”> Dominican Republic </option>
<option value=”Ecuador”> Ecuador </option>
<option value=”Egypt”> Egypt </option>
<option value=”El Salvador”> El Salvador </option>
<option value=”Equatorial Guinea”> Equatorial Guinea </option>
<option value=”Eritrea”> Eritrea </option>
<option value=”Estonia”> Estonia </option>
<option value=”Ethiopia”> Ethiopia </option>
<option value=”Falkland Islands”> Falkland Islands </option>
<option value=”Faroe Islands”> Faroe Islands </option>
<option value=”Fiji”> Fiji </option>
<option value=”Finland”> Finland </option>
<option value=”France”> France </option>
<option value=”French Polynesia”> French Polynesia </option>
<option value=”Gabon”> Gabon </option>
<option value=”The Gambia”> The Gambia </option>
<option value=”Georgia”> Georgia </option>
<option value=”Germany”> Germany </option>
<option value=”Ghana”> Ghana </option>
<option value=”Gibraltar”> Gibraltar </option>
<option value=”Greece”> Greece </option>
<option value=”Greenland”> Greenland </option>
<option value=”Grenada”> Grenada </option>
<option value=”Guadeloupe”> Guadeloupe </option>
<option value=”Guam”> Guam </option>
<option value=”Guatemala”> Guatemala </option>
<option value=”Guernsey”> Guernsey </option>
<option value=”Guinea”> Guinea </option>
<option value=”Guinea-Bissau”> Guinea-Bissau </option>
<option value=”Guyana”> Guyana </option>
<option value=”Haiti”> Haiti </option>
<option value=”Honduras”> Honduras </option>
<option value=”Hong Kong”> Hong Kong </option>
<option value=”Hungary”> Hungary </option>
<option value=”Iceland”> Iceland </option>
<option value=”India”> India </option>
<option value=”Indonesia”> Indonesia </option>
<option value=”Iran”> Iran </option>
<option value=”Iraq”> Iraq </option>
<option value=”Ireland”> Ireland </option>
<option value=”Israel”> Israel </option>
<option value=”Italy”> Italy </option>
<option value=”Jamaica”> Jamaica </option>
<option value=”Japan”> Japan </option>
<option value=”Jersey”> Jersey </option>
<option value=”Jordan”> Jordan </option>
<option value=”Kazakhstan”> Kazakhstan </option>
<option value=”Kenya”> Kenya </option>
<option value=”Kiribati”> Kiribati </option>
<option value=”North Korea”> North Korea </option>
<option value=”South Korea”> South Korea </option>
<option value=”Kosovo”> Kosovo </option>
<option value=”Kuwait”> Kuwait </option>
<option value=”Kyrgyzstan”> Kyrgyzstan </option>
<option value=”Laos”> Laos </option>
<option value=”Latvia”> Latvia </option>
<option value=”Lebanon”> Lebanon </option>
<option value=”Lesotho”> Lesotho </option>
<option value=”Liberia”> Liberia </option>
<option value=”Libya”> Libya </option>
<option value=”Liechtenstein”> Liechtenstein </option>
<option value=”Lithuania”> Lithuania </option>
<option value=”Luxembourg”> Luxembourg </option>
<option value=”Macau”> Macau </option>
<option value=”Macedonia”> Macedonia </option>
<option value=”Madagascar”> Madagascar </option>
<option value=”Malawi”> Malawi </option>
<option value=”Malaysia”> Malaysia </option>
<option value=”Maldives”> Maldives </option>
<option value=”Mali”> Mali </option>
<option value=”Malta”> Malta </option>
<option value=”Marshall Islands”> Marshall Islands </option>
<option value=”Martinique”> Martinique </option>
<option value=”Mauritania”> Mauritania </option>
<option value=”Mauritius”> Mauritius </option>
<option value=”Mayotte”> Mayotte </option>
<option value=”Mexico”> Mexico </option>
<option value=”Micronesia”> Micronesia </option>
<option value=”Moldova”> Moldova </option>
<option value=”Monaco”> Monaco </option>
<option value=”Mongolia”> Mongolia </option>
<option value=”Montenegro”> Montenegro </option>
<option value=”Montserrat”> Montserrat </option>
<option value=”Morocco”> Morocco </option>
<option value=”Mozambique”> Mozambique </option>
<option value=”Myanmar”> Myanmar </option>
<option value=”Nagorno-Karabakh”> Nagorno-Karabakh </option>
<option value=”Namibia”> Namibia </option>
<option value=”Nauru”> Nauru </option>
<option value=”Nepal”> Nepal </option>
<option value=”Netherlands”> Netherlands </option>
<option value=”Netherlands Antilles”> Netherlands Antilles </option>
<option value=”New Caledonia”> New Caledonia </option>
<option value=”New Zealand”> New Zealand </option>
<option value=”Nicaragua”> Nicaragua </option>
<option value=”Niger”> Niger </option>
<option value=”Nigeria”> Nigeria </option>
<option value=”Niue”> Niue </option>
<option value=”Norfolk Island”> Norfolk Island </option>
<option value=”Turkish Republic of Northern Cyprus”> Turkish Republic of Northern Cyprus </option>
<option value=”Northern Mariana”> Northern Mariana </option>
<option value=”Norway”> Norway </option>
<option value=”Oman”> Oman </option>
<option value=”Pakistan”> Pakistan </option>
<option value=”Palau”> Palau </option>
<option value=”Palestine”> Palestine </option>
<option value=”Panama”> Panama </option>
<option value=”Papua New Guinea”> Papua New Guinea </option>
<option value=”Paraguay”> Paraguay </option>
<option value=”Peru”> Peru </option>
<option value=”Philippines”> Philippines </option>
<option value=”Pitcairn Islands”> Pitcairn Islands </option>
<option value=”Poland”> Poland </option>
<option value=”Portugal”> Portugal </option>
<option value=”Puerto Rico”> Puerto Rico </option>
<option value=”Qatar”> Qatar </option>
<option value=”Republic of the Congo”> Republic of the Congo </option>
<option value=”Romania”> Romania </option>
<option value=”Russia”> Russia </option>
<option value=”Rwanda”> Rwanda </option>
<option value=”Saint Barthelemy”> Saint Barthelemy </option>
<option value=”Saint Helena”> Saint Helena </option>
<option value=”Saint Kitts and Nevis”> Saint Kitts and Nevis </option>
<option value=”Saint Lucia”> Saint Lucia </option>
<option value=”Saint Martin”> Saint Martin </option>
<option value=”Saint Pierre and Miquelon”> Saint Pierre and Miquelon </option>
<option value=”Saint Vincent and the Grenadines”> Saint Vincent and the Grenadines </option>
<option value=”Samoa”> Samoa </option>
<option value=”San Marino”> San Marino </option>
<option value=”Sao Tome and Principe”> Sao Tome and Principe </option>
<option value=”Saudi Arabia”> Saudi Arabia </option>
<option value=”Senegal”> Senegal </option>
<option value=”Serbia”> Serbia </option>
<option value=”Seychelles”> Seychelles </option>
<option value=”Sierra Leone”> Sierra Leone </option>
<option value=”Singapore”> Singapore </option>
<option value=”Slovakia”> Slovakia </option>
<option value=”Slovenia”> Slovenia </option>
<option value=”Solomon Islands”> Solomon Islands </option>
<option value=”Somalia”> Somalia </option>
<option value=”Somaliland”> Somaliland </option>
<option value=”South Africa”> South Africa </option>
<option value=”South Ossetia”> South Ossetia </option>
<option value=”South Sudan”> South Sudan </option>
<option value=”Spain”> Spain </option>
<option value=”Sri Lanka”> Sri Lanka </option>
<option value=”Sudan”> Sudan </option>
<option value=”Suriname”> Suriname </option>
<option value=”Svalbard”> Svalbard </option>
<option value=”eSwatini”> eSwatini </option>
<option value=”Sweden”> Sweden </option>
<option value=”Switzerland”> Switzerland </option>
<option value=”Syria”> Syria </option>
<option value=”Taiwan”> Taiwan </option>
<option value=”Tajikistan”> Tajikistan </option>
<option value=”Tanzania”> Tanzania </option>
<option value=”Thailand”> Thailand </option>
<option value=”Timor-Leste”> Timor-Leste </option>
<option value=”Togo”> Togo </option>
<option value=”Tokelau”> Tokelau </option>
<option value=”Tonga”> Tonga </option>
<option value=”Transnistria Pridnestrovie”> Transnistria Pridnestrovie </option>
<option value=”Trinidad and Tobago”> Trinidad and Tobago </option>
<option value=”Tristan da Cunha”> Tristan da Cunha </option>
<option value=”Tunisia”> Tunisia </option>
<option value=”Turkey”> Turkey </option>
<option value=”Turkmenistan”> Turkmenistan </option>
<option value=”Turks and Caicos Islands”> Turks and Caicos Islands </option>
<option value=”Tuvalu”> Tuvalu </option>
<option value=”Uganda”> Uganda </option>
<option value=”Ukraine”> Ukraine </option>
<option value=”United Arab Emirates”> United Arab Emirates </option>
<option value=”United Kingdom”> United Kingdom </option>
<option value=”Uruguay”> Uruguay </option>
<option value=”Uzbekistan”> Uzbekistan </option>
<option value=”Vanuatu”> Vanuatu </option>
<option value=”Vatican City”> Vatican City </option>
<option value=”Venezuela”> Venezuela </option>
<option value=”Vietnam”> Vietnam </option>
<option value=”British Virgin Islands”> British Virgin Islands </option>
<option value=”Isle of Man”> Isle of Man </option>
<option value=”US Virgin Islands”> US Virgin Islands </option>
<option value=”Wallis and Futuna”> Wallis and Futuna </option>
<option value=”Western Sahara”> Western Sahara </option>
<option value=”Yemen”> Yemen </option>
<option value=”Zambia”> Zambia </option>
<option value=”Zimbabwe”> Zimbabwe </option>
<option value=”other”> Other </option>
</select>
<label class=”form-sub-label” for=”input_7_country” id=”sublabel_7_country” style=”min-height:13px”> Country </label>
</span>
</td>
</tr>
</tbody>
</table>
</div>
</li>
<li class=”form-line” data-type=”control_fullname” id=”id_9″>
<label class=”form-label form-label-top form-label-auto” id=”label_9″ for=”first_9″> 6. Parent #2 First and Last Name </label>
<div id=”cid_9″ class=”form-input-wide”>
<div data-wrapper-react=”true”>
<span class=”form-sub-label-container ” style=”vertical-align:top”>
<input type=”text” id=”first_9″ name=”q9_6Parent[first]” class=”form-textbox” size=”10″ value=”” data-component=”first” aria-labelledby=”label_9 sublabel_9_first” />
<label class=”form-sub-label” for=”first_9″ id=”sublabel_9_first” style=”min-height:13px”> First Name </label>
</span>
<span class=”form-sub-label-container ” style=”vertical-align:top”>
<input type=”text” id=”last_9″ name=”q9_6Parent[last]” class=”form-textbox” size=”15″ value=”” data-component=”last” aria-labelledby=”label_9 sublabel_9_last” />
<label class=”form-sub-label” for=”last_9″ id=”sublabel_9_last” style=”min-height:13px”> Last Name </label>
</span>
</div>
</div>
</li>
<li class=”form-line” data-type=”control_email” id=”id_10″>
<label class=”form-label form-label-top form-label-auto” id=”label_10″ for=”input_10″> 7. Parent #2 Email Address </label>
<div id=”cid_10″ class=”form-input-wide”>
<span class=”form-sub-label-container ” style=”vertical-align:top”>
<input type=”email” id=”input_10″ name=”q10_7Parent” class=”form-textbox validate[Email]” size=”30″ value=”” data-component=”email” aria-labelledby=”label_10 sublabel_input_10″ />
<label class=”form-sub-label” for=”input_10″ id=”sublabel_input_10″ style=”min-height:13px”> example@example.com </label>
</span>
</div>
</li>
<li class=”form-line” data-type=”control_textbox” id=”id_12″>
<label class=”form-label form-label-top form-label-auto” id=”label_12″ for=”input_12″> 8. Parent #2 Occupation </label>
<div id=”cid_12″ class=”form-input-wide”>
<input type=”text” id=”input_12″ name=”q12_8Parent” data-type=”input-textbox” class=”form-textbox” size=”20″ value=”” data-component=”textbox” aria-labelledby=”label_12″ />
</div>
</li>
<li class=”form-line jf-required” data-type=”control_radio” id=”id_26″>
<label class=”form-label form-label-top form-label-auto” id=”label_26″ for=”input_26″>
Do both parents live in the same house?
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_26″ class=”form-input-wide jf-required”>
<div class=”form-single-column” role=”group” aria-labelledby=”label_26″ data-component=”radio”>
<span class=”form-radio-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”radio” class=”form-radio validate[required]” id=”input_26_0″ name=”q26_doBoth” value=”Yes” required=”” />
<label id=”label_input_26_0″ for=”input_26_0″> Yes </label>
</span>
<span class=”form-radio-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”radio” class=”form-radio validate[required]” id=”input_26_1″ name=”q26_doBoth” value=”No” required=”” />
<label id=”label_input_26_1″ for=”input_26_1″> No </label>
</span>
</div>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_radio” id=”id_19″>
<label class=”form-label form-label-top form-label-auto” id=”label_19″ for=”input_19″>
Has your family used a nanny placement service before?
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_19″ class=”form-input-wide jf-required”>
<div class=”form-single-column” role=”group” aria-labelledby=”label_19″ data-component=”radio”>
<span class=”form-radio-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”radio” class=”form-radio validate[required]” id=”input_19_0″ name=”q19_hasYour” value=”Yes” required=”” />
<label id=”label_input_19_0″ for=”input_19_0″> Yes </label>
</span>
<span class=”form-radio-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”radio” class=”form-radio validate[required]” id=”input_19_1″ name=”q19_hasYour” value=”No” required=”” />
<label id=”label_input_19_1″ for=”input_19_1″> No </label>
</span>
</div>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_radio” id=”id_13″>
<label class=”form-label form-label-top form-label-auto” id=”label_13″ for=”input_13″>
Will Childcare be provided in the Home?
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_13″ class=”form-input-wide jf-required”>
<div class=”form-single-column” role=”group” aria-labelledby=”label_13″ data-component=”radio”>
<span class=”form-radio-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”radio” class=”form-radio validate[required]” id=”input_13_0″ name=”q13_willChildcare13″ value=”Yes” required=”” />
<label id=”label_input_13_0″ for=”input_13_0″> Yes </label>
</span>
<span class=”form-radio-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”radio” class=”form-radio validate[required]” id=”input_13_1″ name=”q13_willChildcare13″ value=”No” required=”” />
<label id=”label_input_13_1″ for=”input_13_1″> No </label>
</span>
</div>
</div>
</li>
<li class=”form-line” data-type=”control_textbox” id=”id_14″>
<label class=”form-label form-label-top form-label-auto” id=”label_14″ for=”input_14″> If Answered No, Where Will Childcare Take Place? (Address) </label>
<div id=”cid_14″ class=”form-input-wide”>
<input type=”text” id=”input_14″ name=”q14_ifAnswered” data-type=”input-textbox” class=”form-textbox” size=”20″ value=”” data-component=”textbox” aria-labelledby=”label_14″ />
</div>
</li>
<li class=”form-line jf-required” data-type=”control_textarea” id=”id_15″>
<label class=”form-label form-label-top form-label-auto” id=”label_15″ for=”input_15″>
Please list names / ages/ birthdates of each child
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_15″ class=”form-input-wide jf-required”>
<textarea id=”input_15″ class=”form-textarea validate[required]” name=”q15_pleaseList15″ cols=”40″ rows=”6″ data-component=”textarea” required=”” aria-labelledby=”label_15″></textarea>
</div>
</li>
<li class=”form-line” data-type=”control_textarea” id=”id_16″>
<label class=”form-label form-label-top form-label-auto” id=”label_16″ for=”input_16″> Please List Any Food Allergies (Ex: Emma, allergic to peanuts) </label>
<div id=”cid_16″ class=”form-input-wide”>
<textarea id=”input_16″ class=”form-textarea” name=”q16_pleaseList16″ cols=”40″ rows=”6″ data-component=”textarea” aria-labelledby=”label_16″></textarea>
</div>
</li>
<li class=”form-line” data-type=”control_textarea” id=”id_17″>
<label class=”form-label form-label-top form-label-auto” id=”label_17″ for=”input_17″> Please List Name / Type of Pets in the Home </label>
<div id=”cid_17″ class=”form-input-wide”>
<textarea id=”input_17″ class=”form-textarea” name=”q17_pleaseList17″ cols=”40″ rows=”6″ data-component=”textarea” aria-labelledby=”label_17″></textarea>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_textarea” id=”id_18″>
<label class=”form-label form-label-top form-label-auto” id=”label_18″ for=”input_18″>
Please Write Any Special Needs the Child Has That Would Impact Childcare (Ex. ADHD, Autism, etc) If none, please write N/A
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_18″ class=”form-input-wide jf-required”>
<textarea id=”input_18″ class=”form-textarea validate[required]” name=”q18_pleaseWrite18″ cols=”40″ rows=”6″ data-component=”textarea” required=”” aria-labelledby=”label_18″></textarea>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_textarea” id=”id_20″>
<label class=”form-label form-label-top form-label-auto” id=”label_20″ for=”input_20″>
Please describe the temperament of each child
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_20″ class=”form-input-wide jf-required”>
<textarea id=”input_20″ class=”form-textarea validate[required]” name=”q20_pleaseDescribe” cols=”40″ rows=”6″ data-component=”textarea” required=”” aria-labelledby=”label_20″></textarea>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_textarea” id=”id_21″>
<label class=”form-label form-label-top form-label-auto” id=”label_21″ for=”input_21″>
Please describe the likes / dislikes of each child
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_21″ class=”form-input-wide jf-required”>
<textarea id=”input_21″ class=”form-textarea validate[required]” name=”q21_pleaseDescribe21″ cols=”40″ rows=”6″ data-component=”textarea” required=”” aria-labelledby=”label_21″></textarea>
</div>
</li>
<li class=”form-line” data-type=”control_textarea” id=”id_22″>
<label class=”form-label form-label-top form-label-auto” id=”label_22″ for=”input_22″> Please put in each child’s grade and school / daycare hours if applicable </label>
<div id=”cid_22″ class=”form-input-wide”>
<textarea id=”input_22″ class=”form-textarea” name=”q22_pleasePut22″ cols=”40″ rows=”6″ data-component=”textarea” aria-labelledby=”label_22″></textarea>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_checkbox” id=”id_23″>
<label class=”form-label form-label-top form-label-auto” id=”label_23″ for=”input_23″>
Job Type
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_23″ class=”form-input-wide jf-required”>
<div class=”form-single-column” role=”group” aria-labelledby=”label_23″ data-component=”checkbox”>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_23_0″ name=”q23_jobType[]” value=”Full-Time (35+ hours per week)” required=”” />
<label id=”label_input_23_0″ for=”input_23_0″> Full-Time (35+ hours per week) </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_23_1″ name=”q23_jobType[]” value=”Part-Time (20-35 hours per week)” required=”” />
<label id=”label_input_23_1″ for=”input_23_1″> Part-Time (20-35 hours per week) </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_23_2″ name=”q23_jobType[]” value=”Live-In” required=”” />
<label id=”label_input_23_2″ for=”input_23_2″> Live-In </label>
</span>
</div>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_checkbox” id=”id_24″>
<label class=”form-label form-label-top form-label-auto” id=”label_24″ for=”input_24″>
Please check off the benefits you will be offering
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_24″ class=”form-input-wide jf-required”>
<div class=”form-single-column” role=”group” aria-labelledby=”label_24″ data-component=”checkbox”>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_24_0″ name=”q24_pleaseCheck[]” value=”Paid Sick Time” required=”” />
<label id=”label_input_24_0″ for=”input_24_0″> Paid Sick Time </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_24_1″ name=”q24_pleaseCheck[]” value=”Paid Vacation” required=”” />
<label id=”label_input_24_1″ for=”input_24_1″> Paid Vacation </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_24_2″ name=”q24_pleaseCheck[]” value=”Paid Holidays” required=”” />
<label id=”label_input_24_2″ for=”input_24_2″> Paid Holidays </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_24_3″ name=”q24_pleaseCheck[]” value=”Healthcare Stipend” required=”” />
<label id=”label_input_24_3″ for=”input_24_3″> Healthcare Stipend </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_24_4″ name=”q24_pleaseCheck[]” value=”Mileage Reimbursement” required=”” />
<label id=”label_input_24_4″ for=”input_24_4″> Mileage Reimbursement </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_24_5″ name=”q24_pleaseCheck[]” value=”Cell Phone Reimbursement” required=”” />
<label id=”label_input_24_5″ for=”input_24_5″> Cell Phone Reimbursement </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_24_6″ name=”q24_pleaseCheck[]” value=”Retirement Contribution” required=”” />
<label id=”label_input_24_6″ for=”input_24_6″> Retirement Contribution </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_24_7″ name=”q24_pleaseCheck[]” value=”Professional Development Stipend” required=”” />
<label id=”label_input_24_7″ for=”input_24_7″> Professional Development Stipend </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_24_8″ name=”q24_pleaseCheck[]” value=”Other” required=”” />
<label id=”label_input_24_8″ for=”input_24_8″> Other </label>
</span>
</div>
</div>
</li>
<li class=”form-line” data-type=”control_checkbox” id=”id_27″>
<label class=”form-label form-label-top form-label-auto” id=”label_27″ for=”input_27″> If one or both parents will be home, please select an option below </label>
<div id=”cid_27″ class=”form-input-wide”>
<div class=”form-single-column” role=”group” aria-labelledby=”label_27″ data-component=”checkbox”>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox” id=”input_27_0″ name=”q27_ifOne[]” value=”Stay at Home Parent” />
<label id=”label_input_27_0″ for=”input_27_0″> Stay at Home Parent </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox” id=”input_27_1″ name=”q27_ifOne[]” value=”Work at Home Parent Full-time” />
<label id=”label_input_27_1″ for=”input_27_1″> Work at Home Parent Full-time </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox” id=”input_27_2″ name=”q27_ifOne[]” value=”Work at Home Parent Part-time” />
<label id=”label_input_27_2″ for=”input_27_2″> Work at Home Parent Part-time </label>
</span>
</div>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_textarea” id=”id_28″>
<label class=”form-label form-label-top form-label-auto” id=”label_28″ for=”input_28″>
Please type out the nanny’s schedule for each day of the week. Please write out every day of the week, including Saturday and Sunday. Write N/A next to any days that the nanny will not work.
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_28″ class=”form-input-wide jf-required”>
<textarea id=”input_28″ class=”form-textarea validate[required]” name=”q28_pleaseType” cols=”40″ rows=”6″ data-component=”textarea” required=”” aria-labelledby=”label_28″></textarea>
</div>
</li>
<li class=”form-line” data-type=”control_checkbox” id=”id_29″>
<label class=”form-label form-label-top form-label-auto” id=”label_29″ for=”input_29″> Please check off additional availability that will be required from the job </label>
<div id=”cid_29″ class=”form-input-wide”>
<div class=”form-single-column” role=”group” aria-labelledby=”label_29″ data-component=”checkbox”>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox” id=”input_29_0″ name=”q29_pleaseCheck29[]” value=”Evenings” />
<label id=”label_input_29_0″ for=”input_29_0″> Evenings </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox” id=”input_29_1″ name=”q29_pleaseCheck29[]” value=”Weekends” />
<label id=”label_input_29_1″ for=”input_29_1″> Weekends </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox” id=”input_29_2″ name=”q29_pleaseCheck29[]” value=”Travel” />
<label id=”label_input_29_2″ for=”input_29_2″> Travel </label>
</span>
</div>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_textarea” id=”id_30″>
<label class=”form-label form-label-top form-label-auto” id=”label_30″ for=”input_30″>
Please write a job description including the most important tasks
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_30″ class=”form-input-wide jf-required”>
<textarea id=”input_30″ class=”form-textarea validate[required]” name=”q30_pleaseWrite” cols=”40″ rows=”6″ data-component=”textarea” required=”” aria-labelledby=”label_30″></textarea>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_checkbox” id=”id_39″>
<label class=”form-label form-label-top form-label-auto” id=”label_39″ for=”input_39″>
What is the proposed salary for the position?
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_39″ class=”form-input-wide jf-required”>
<div class=”form-single-column” role=”group” aria-labelledby=”label_39″ data-component=”checkbox”>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_39_0″ name=”q39_whatIs[]” value=”$22-25 per hour” required=”” />
<label id=”label_input_39_0″ for=”input_39_0″> $22-25 per hour </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_39_1″ name=”q39_whatIs[]” value=”$25-30 per hour” required=”” />
<label id=”label_input_39_1″ for=”input_39_1″> $25-30 per hour </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_39_2″ name=”q39_whatIs[]” value=”$30 + per hour” required=”” />
<label id=”label_input_39_2″ for=”input_39_2″> $30 + per hour </label>
</span>
</div>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_textarea” id=”id_31″>
<label class=”form-label form-label-top form-label-auto” id=”label_31″ for=”input_31″>
What characteristics are you looking for in a nanny?
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_31″ class=”form-input-wide jf-required”>
<textarea id=”input_31″ class=”form-textarea validate[required]” name=”q31_whatCharacteristics” cols=”40″ rows=”6″ data-component=”textarea” required=”” aria-labelledby=”label_31″></textarea>
</div>
</li>
<li class=”form-line” data-type=”control_textarea” id=”id_32″>
<label class=”form-label form-label-top form-label-auto” id=”label_32″ for=”input_32″> Please list any other individuals that live at the home where the childcare will take place </label>
<div id=”cid_32″ class=”form-input-wide”>
<textarea id=”input_32″ class=”form-textarea” name=”q32_pleaseList” cols=”40″ rows=”6″ data-component=”textarea” aria-labelledby=”label_32″></textarea>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_radio” id=”id_33″>
<label class=”form-label form-label-top form-label-auto” id=”label_33″ for=”input_33″>
Do you have surveillance or video cameras in the home?
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_33″ class=”form-input-wide jf-required”>
<div class=”form-single-column” role=”group” aria-labelledby=”label_33″ data-component=”radio”>
<span class=”form-radio-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”radio” class=”form-radio validate[required]” id=”input_33_0″ name=”q33_doYou” value=”Yes” required=”” />
<label id=”label_input_33_0″ for=”input_33_0″> Yes </label>
</span>
<span class=”form-radio-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”radio” class=”form-radio validate[required]” id=”input_33_1″ name=”q33_doYou” value=”No” required=”” />
<label id=”label_input_33_1″ for=”input_33_1″> No </label>
</span>
</div>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_checkbox” id=”id_34″>
<label class=”form-label form-label-top form-label-auto” id=”label_34″ for=”input_34″>
Will there be a family car available for the nanny to drive?
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_34″ class=”form-input-wide jf-required”>
<div class=”form-single-column” role=”group” aria-labelledby=”label_34″ data-component=”checkbox”>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_34_0″ name=”q34_willThere[]” value=”Yes” required=”” />
<label id=”label_input_34_0″ for=”input_34_0″> Yes </label>
</span>
<span class=”form-checkbox-item” style=”clear:left”>
<span class=”dragger-item”>
</span>
<input type=”checkbox” class=”form-checkbox validate[required]” id=”input_34_1″ name=”q34_willThere[]” value=”No” required=”” />
<label id=”label_input_34_1″ for=”input_34_1″> No </label>
</span>
</div>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_fullname” id=”id_35″>
<label class=”form-label form-label-top form-label-auto” id=”label_35″ for=”first_35″>
Reference #1 Name
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_35″ class=”form-input-wide jf-required”>
<div data-wrapper-react=”true”>
<span class=”form-sub-label-container ” style=”vertical-align:top”>
<input type=”text” id=”first_35″ name=”q35_reference1[first]” class=”form-textbox validate[required]” size=”10″ value=”” data-component=”first” aria-labelledby=”label_35 sublabel_35_first” required=”” />
<label class=”form-sub-label” for=”first_35″ id=”sublabel_35_first” style=”min-height:13px”> First Name </label>
</span>
<span class=”form-sub-label-container ” style=”vertical-align:top”>
<input type=”text” id=”last_35″ name=”q35_reference1[last]” class=”form-textbox validate[required]” size=”15″ value=”” data-component=”last” aria-labelledby=”label_35 sublabel_35_last” required=”” />
<label class=”form-sub-label” for=”last_35″ id=”sublabel_35_last” style=”min-height:13px”> Last Name </label>
</span>
</div>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_phone” id=”id_36″>
<label class=”form-label form-label-top form-label-auto” id=”label_36″ for=”input_36_area”>
Reference #1 Phone
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_36″ class=”form-input-wide jf-required”>
<div data-wrapper-react=”true”>
<span class=”form-sub-label-container ” style=”vertical-align:top”>
<input type=”tel” id=”input_36_area” name=”q36_reference136[area]” class=”form-textbox validate[required]” size=”6″ value=”” data-component=”areaCode” aria-labelledby=”label_36 sublabel_36_area” required=”” />
<span class=”phone-separate” aria-hidden=”true”>

</span>
<label class=”form-sub-label” for=”input_36_area” id=”sublabel_36_area” style=”min-height:13px”> Area Code </label>
</span>
<span class=”form-sub-label-container ” style=”vertical-align:top”>
<input type=”tel” id=”input_36_phone” name=”q36_reference136[phone]” class=”form-textbox validate[required]” size=”12″ value=”” data-component=”phone” aria-labelledby=”label_36 sublabel_36_phone” required=”” />
<label class=”form-sub-label” for=”input_36_phone” id=”sublabel_36_phone” style=”min-height:13px”> Phone Number </label>
</span>
</div>
</div>
</li>
<li class=”form-line” data-type=”control_email” id=”id_37″>
<label class=”form-label form-label-top form-label-auto” id=”label_37″ for=”input_37″> Reference #1 Email Address </label>
<div id=”cid_37″ class=”form-input-wide”>
<span class=”form-sub-label-container ” style=”vertical-align:top”>
<input type=”email” id=”input_37″ name=”q37_reference137″ class=”form-textbox validate[Email]” size=”30″ value=”” data-component=”email” aria-labelledby=”label_37 sublabel_input_37″ />
<label class=”form-sub-label” for=”input_37″ id=”sublabel_input_37″ style=”min-height:13px”> example@example.com </label>
</span>
</div>
</li>
<li class=”form-line jf-required” data-type=”control_textarea” id=”id_38″>
<label class=”form-label form-label-top form-label-auto” id=”label_38″ for=”input_38″>
Please initial this box. You are agreeing to pay a non-refundable $250 application fee to initiate the search that will go towards your placement fee if you choose a nanny through our agency. Once the application fee is paid, My City Baby Nurse and Nanny will send an employer / agency contract fee via email that will need to be signed before the nanny search is started. I agree to sign and return the contract, and I agree to the above statement when I initial in the box below. I also agree to adhere to this statement.
<span class=”form-required”>
*
</span>
</label>
<div id=”cid_38″ class=”form-input-wide jf-required”>
<textarea id=”input_38″ class=”form-textarea validate[required]” name=”q38_pleaseInitial” cols=”40″ rows=”6″ data-component=”textarea” required=”” aria-labelledby=”label_38″></textarea>
</div>
</li>
<li class=”form-line” data-type=”control_button” id=”id_2″>
<div id=”cid_2″ class=”form-input-wide”>
<div style=”margin-left:156px” class=”form-buttons-wrapper “>
<button id=”input_2″ type=”submit” class=”form-submit-button” data-component=”button” data-content=””>
Submit
</button>
</div>
</div>
</li>
<li style=”display:none”>
Should be Empty:
<input type=”text” name=”website” value=”” />
</li>
</ul>
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