Nanny Placement - Family Application 1. Parent #1 First and Last Name * First Name Last Name 2. Parent #1 Email Address * example@example.com 3. Parent #1 Phone Number * - Area Code Phone Number 4. Parent #1 Occupation * 5. Family Address * Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard eSwatini Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country 6. Parent #2 First and Last Name First Name Last Name 7. Parent #2 Email Address example@example.com 8. Parent #2 Occupation Do both parents live in the same house? * Yes No Has your family used a nanny placement service before? * Yes No Will Childcare be provided in the Home? * Yes No If Answered No, Where Will Childcare Take Place? (Address) Please list names / ages/ birthdates of each child * Please List Any Food Allergies (Ex: Emma, allergic to peanuts) Please List Name / Type of Pets in the Home Please Write Any Special Needs the Child Has That Would Impact Childcare (Ex. ADHD, Autism, etc) If none, please write N/A * Please describe the temperament of each child * Please describe the likes / dislikes of each child * Please put in each child's grade and school / daycare hours if applicable Job Type * Full-Time (35+ hours per week) Part-Time (20-35 hours per week) Live-In Please check off the benefits you will be offering * Paid Sick Time Paid Vacation Paid Holidays Healthcare Stipend Mileage Reimbursement Cell Phone Reimbursement Retirement Contribution Professional Development Stipend Other If one or both parents will be home, please select an option below Stay at Home Parent Work at Home Parent Full-time Work at Home Parent Part-time 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. * Please check off additional availability that will be required from the job Evenings Weekends Travel Please write a job description including the most important tasks * What is the proposed salary for the position? * $22-25 per hour $25-30 per hour $30 + per hour What characteristics are you looking for in a nanny? * Please list any other individuals that live at the home where the childcare will take place Do you have surveillance or video cameras in the home? * Yes No Will there be a family car available for the nanny to drive? * Yes No Reference #1 Name * First Name Last Name Reference #1 Phone * - Area Code Phone Number Reference #1 Email Address example@example.com 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. * Submit Should be Empty:
