AMERICAN NANNY JOB SEARCH

Online Nanny Application

To request more information, please fill out the following form.

Before you fill out the form, please review our nanny qualifications.

	NANNY QUALIFICATIONS
	1. at least 18 years old 2. a US citizen (or green card) 3. a High School graduate 4. willing to commit to a one year agreement 5. ability to relocate to another city in the U.S.

*PERSONAL INFORMATION*
Full Name:		Age:	Date of Birth:
E-mail Address:
Current Address:
City: State: Zip:
Phone Number: SSN:
Are you a U.S. citizen? Yes No
If No, can you legally work in the U.S.? Yes No
Height?	Weight?

*FAMILY AND PERSONAL BACKGROUND*
Do you live with your parents? Yes No		Parent's Names
Parent's Address
Mother's Occupation:		Mother's Phone Number:
Father's Occupation:		Father's Phone Number:
Number of brothers:	Number of sisters:	Where do you fit?
Do you have any children: Yes No			Marital Status:
Involvement with youth-oriented organizations:
Do you have any experience with special needs children: Yes No
If yes, please explain:
Are you certified in CPR? Yes No		Are you certified in First Aid? Yes No
Can you swim? Yes No		Are you certified in lifesaving? Yes No
Do you drive? Yes No		Will you bring a vehicle with you? Yes No
Driver's License No.	State:	Can you operate a stick shift?
Have you ever had any traffic accidents or traffice tickets? Yes No
If yes, please explain
Have you ever been arrested? Yes No		If yes, explain:
Have you ever convicted of a crime? Yes No		If yes, explain:

*EMERGENCY CONTACT INFORMATION*
Name		Relationship
Current Address		Phone Number
City: State: Zip:

JOB INFORMATION

Geographic areas preferred:

Available starting date		Requested salary
Do you want a permanent position? Yes No		Do you want summer work only? Yes No
Ages/most number of children you've cared for
Would you work in a single parent home? Yes No
Do you prefer to work in a home where the mother works? Yes No
Are you willing to do housekeeping for additional money? Yes No
How do you rate yourself as a cook? Good Fair Poor

*WORK EXPERIENCE* Current or most recent employment only
Dates		Employer
From	To	Name	City/State	Phone No.	Supervisor's Name

*EDUCATION*
High School Name(s) and Location(s):
Years Attended:	Did you graduate? Yes No	If yes, what year?
Extracurricular activities:
College Name(s) and Location(s):
Years Attended:	Major?	If yes, what year?
Extracurricular activities:
Did you graduate? Yes No		If yes, what year?
Child-related courses:

*REFERENCES*
Personal Reference Please list someone who has known you for at least three years, such as a teacher, coach, minister, etc. Do not list anyone related to you.
Name:	Phone Number:
Years Known:	Relationship:
Childcare References Please list three people who have observed you with children or who have supervised your work with children. Do not list anyone related to you.
Name:	Phone Number:
Relationship:	Ages of Children	When
Name:	Phone Number:
Relationship:	Ages of Children	When
Name:	Phone Number:
Relationship:	Ages of Children	When

*HEALTH INFORMATION*
Have you ever had any hospital stay? Yes No		If yes, when and why:
Do you smoke? Yes No	If yes, how much?
Are you currently taking any medication? Yes No		If yes, please explain:

Please check if you have ever had any of the following:
None
Allergies	Asthma	Anorexia or Bulimia
AIDS	High Blood Pressure	Epilespsy
Hernia	Fainting or Dizziness	Emotional Problems
Cancer	Convulsions	Menstrual Problems
Diabetes	Heart Disease	Leukemia
Sexually Tranmitted Disease
Please check if you are allergic to any of the following:
None
Insect Bites	Medicines	Plants	Foods
Animals	Other

If Other, please explain:
Other than routine exams, have you consulted with/been treated by a physician in the past 5 years? Yes No
Have you ever been treated for mental or emotional problems? Yes No
Do you have any physical restrictions or impairments? Yes No
Do you drugs or alcohol? Yes No
Have you every been teated for drugs/alcohol abuse? Yes No
Do you have any dietary restrictions? Yes No
Do you have any eating diorders? Yes No
How did you hear about us?
*AUTHORIZATION*
By submitting this form, I hereby certify that the above information is true and correct, to the best of my knowledge.

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