Permanent Address: City: State:

Zip:

Temporary or College Address: City:

State:

Zip:

Email Address (required):

Day Telephone: Evening Phone:

Cell Phone: Date of Birth:

Available Start Date:

Schedule Desired:

Please explain flexibility and restrictions for desired schedule:

Desired Salary Range: $ Prior Hourly Rate in Previous Job: $

Weekly Minimum Salary Expectation: $

Are you 18 years of age or older?: Yes No Do you smoke?: Yes No Opposed to Smoking?: Yes No

Are you a United State Citizen?: Yes No Are you eligible to work in the U.S.?: Yes No

Driver's License?: Yes No State & Number:

Have you ever had a moving or driving violation or traffic accident (including tickets)?: Yes No

If 'yes' list specifics:

Have you ever been arrested or convicted of a felony and/or a misdemeanor?: Yes No

If 'yes' list specifics:

Have you ever been the subject of a substantiated complaint of child or sexual abuse?: Yes No

If 'yes' list specifics:

Are you First Aid certified?: Yes No Are you CPR certified?: Yes No Do you swim: Yes No

Please list any pets that you are NOT comfortable working around or living with:

Medical Information

Do you have any medical conditions or chronic health problems? Yes No

If 'yes' please describe these conditions or health challenges that affect your physical activity or work capabilities:

For each of the following, please indicate if you are willing to submit to, at no expense to you

Physical Examination: Yes No Drug Testing: Yes No T.B. Test: Yes No H.I.V. Test: Yes No

Have you been immunized against common childhood diseases?: Yes No

If 'no' for which diseases have you NOT been immunized?:

Do you have any diet restrictions?: Yes No If 'yes' please explain:

Do you have any current or history of emotional health problems?: Yes No If 'yes' please explain:

Have you ever been recommended for an alcohol or drug rehabilitation or mental institution?: Yes No

If 'yes' please explain:

Educational Background

Do you have a high school diploma/GED?: Yes No Name of High School:

Name of College (if attended): Dates Attended:

Major:

Degree/Certificated Achieved: Phone Number:

Please list any other certificates, licenses, or training:

Experience with Children

Please describe your experience with children:

Languages you speak other than English:

Music talent or instruments you play:

Athletic abilities or sports you play:

Tutoring capabilities or specialty:

Education or teaching background:

Work, volunteering or leadership involving children or children's programs:

What age children do you prefer for nanny placement?:

House Manager Applicants Only - Answer 'yes' only to questions that reflect professional or real home experience of an advanced level. If you are willing to take a House Manager position with nanny duties, complete the childcare questions along with this section.

Duties that I have performed or have advanced knowledge:

Manage, maintain all household items, and inventory - food, staples, cleaning products: Yes No

Understand the maintenance and routine service for home repairs - air filters, water softener/conditioners, irrigation systems, and similar. Yes No

Please describe experience:

Can supervise or manage lawn care service or gardeners: Yes No

School applications, forms and correspondence: Yes No

Spreadsheet and bill paying software: Yes No

Personal correspondence and assistance with thank you notes, invitations, etc.: Yes No

Help with phone calls, committees, volunteering, scheduling or other family needs: Yes No

Pick up of family members from appointments, activities, airport, or driving as needed: Yes No

Christmas decorating, Christmas cards and gift-wrapping: Yes No

Photo albums and family scrapbooking: Yes No

Appointment scheduling for haircuts, doctor and dentist visits, and other pre-scheduled needs: Yes No

Cooking skills - prepares family style meals and gathers input from family for menu planning: Yes No

Please describe your culinary experience:

All Applicants for All Positions

Please submit only your professional resume and work references to SHSAgency@gmail.com

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.

I certify that I have read and agree to this statement:

Date: