"Job Application Form - Village Nannies"

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VILLAGE NANNIES 
 APPLICATION FORM
DATE: ________________________________
GENERAL INFORMATION
Name:
Address:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Date of Birth:
Social Security #/Social Insurance #:
DRIVING RECORD
Do you have a valid driver’s license?      Yes     No
License #:
State/Province:
Number of accidents/moving violations in which you were a driver in the past 3 years: ___________
Explain:
Are you able to drive a manual transmission?
Do you have your own car?
 Yes      No
 Yes      No
MISCELLANEOUS
Have you ever been convicted of a crime?      Yes      No
If Yes, explain:
Do you smoke?
Do you take drugs?
Do   you   drink   alcoholic
beverages?      Yes      No
 Yes     No
 Yes      No
MEDICAL HISTORY
Do you have any dietary restrictions?      Yes      No
If Yes, explain:
Do you have any medical conditions that may affect your ability to work as a nanny?      Yes      No
If Yes, explain:
What is your energy level?
Are you physically able to work as a nanny?
 Yes      No
VILLAGE NANNIES 
 APPLICATION FORM
DATE: ________________________________
GENERAL INFORMATION
Name:
Address:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Date of Birth:
Social Security #/Social Insurance #:
DRIVING RECORD
Do you have a valid driver’s license?      Yes     No
License #:
State/Province:
Number of accidents/moving violations in which you were a driver in the past 3 years: ___________
Explain:
Are you able to drive a manual transmission?
Do you have your own car?
 Yes      No
 Yes      No
MISCELLANEOUS
Have you ever been convicted of a crime?      Yes      No
If Yes, explain:
Do you smoke?
Do you take drugs?
Do   you   drink   alcoholic
beverages?      Yes      No
 Yes     No
 Yes      No
MEDICAL HISTORY
Do you have any dietary restrictions?      Yes      No
If Yes, explain:
Do you have any medical conditions that may affect your ability to work as a nanny?      Yes      No
If Yes, explain:
What is your energy level?
Are you physically able to work as a nanny?
 Yes      No
­ 2 ­
Do you have any allergies?  Yes      No
Do you take any prescription medications? 
If Yes, explain:
 Yes      No
If Yes, list:
Have you had or do you currently have any psychological problems?  Yes      No
If Yes, explain:
EDUCATION
What is your highest level of education?
School/College/University:
Do you have First Aid/CPR certification?      Yes      No
If Yes, what level? ____________________________________________________
Have you taken any additional courses or training?      Yes      No
If Yes, list:
INTERESTS
Hobbies:
Sports:
Do you like pets?  Yes      No
Do you do housekeeping? 
Do you cook?  Yes      No
Explain:
Explain:
 Yes     No
Explain:
List any other interests that may be relevant:
EMPLOYMENT HISTORY
Dates
Employer
Telephone Number
Duties
NANNY EXPERIENCE
What is your previous nanny experience?
 Live­in Nanny      Live­out Nanny      Mother’s Helper      Other: __________________________
Describe your experience as a nanny/ mother’s helper/babysitter:
­ 3 ­
What is your previous experience working with children?
 Teacher      Teacher’s Aid      Camp Counselor      Babysitter      Raised your own children   
 Other: ___________________________________________
­ 4 ­
What skills have you employed as a nanny (check those that apply):
 Cared for nursing baby                  Prepared formula
 Gave solid foods to baby                Gave medications
 Provided 24 hour childcare
 Helped toilet train a toddler           Taught child to swim
 Cared for sick child (Explain: ________________________________________________________________)
 Other: 
Have you worked with special needs children?      Yes      No
If Yes, explain:
What is your experience working with children of different ages?
 Newborn               How Long: ____________    Explain: _____________________________________
 6­24 months           How Long: ___________     Explain: _____________________________________
 2­5 years                 How Long: ___________     Explain: _____________________________________
 6­12 years               How Long: ___________     Explain: _____________________________________
 Teenagers               How Long: ___________     Explain: _____________________________________
REFERENCES
Please provide a personal reference (not a relative) who has known you at least 3 years:
Name: _________________________________________
Relationship: ___________________________________
Phone No: ______________________________________
CHILDCARE REFERENCES
Dates Worked
Name
Phone Number
Ages of Children
­ 5 ­
Authorization
I,   ____________________________________   [insert   name   of   nanny],   acknowledge   that
_____________________________ [insert name of agency] (the “Agency”) may request a reference check,
which may include information on my character, general reputation, education, personal characteristics,
driving record, police record, and past employment. I hereby authorize the Agency to obtain any such
information.
I acknowledge that I have read and understand this statement and that, to the best of my knowledge, the
information provided in this application is true and correct. 
I agree to release and hold the Agency harmless for any act of the employer. I also agree to hold the
Agency harmless of any claim as a result of any placement in which I am a part.
______________________________________________
Applicant’s Signature
______________________________________________
Date