Employer
Father: Mother:

Business Phone
Father: Mother:

Home Address:

Part of Town: Home Phone:

Child's Name: Age: Sex:

Child's Name: Age: Sex:

Child's Name: Age: Sex:

How did you hear about Solutions Home Staffing?

When do you need a home staff member?

Please check appropriate nanny or caregiver needs if applicable: Live In - Full Time Live In - Part Time Live Out - Full Time Live Out - Part Time

Describe Children's Health:

Please specify any special needs:

Briefly describe children's personalities:

Please describe the type and hours of school that the children attend:

Describe your approach to child rearing and discipline:

Describe a typical schedule that you would expect your caregiver to follow:

Please list any other adults in the home other than the parents:

What other household staff do you employ?

Religion if appropriate:

Do you have any pets? Yes No

Please describe a rhythm of the household. Formal/Informal/Busy etc.:

Please describe the community in which you reside including any public transportation from your home and nearest town or city:

Is smoking allowed in your house? Yes No

Is alcohol allowed in your house? Yes No

What is your policy for the Nanny regarding smoking and alcohol consumption in your home during off duty hours?

Please rate the following according to your importance in finding a nanny.

Experience with children: Very Important Neutral Not Relevant Not Important

Communications skills: Very Important Neutral Not Relevant Not Important

Athletic skills: Very Important Neutral Not Relevant Not Important

Writing skills: Very Important Neutral Not Relevant Not Important

Creativity: Very Important Neutral Not Relevant Not Important

Laundry skills: Very Important Neutral Not Relevant Not Important

Neat appearance: Very Important Neutral Not Relevant Not Important

Education: Very Important Neutral Not Relevant Not Important

Compatible personality: Very Important Neutral Not Relevant Not Important

Music skills: Very Important Neutral Not Relevant Not Important

Organizational skills: Very Important Neutral Not Relevant Not Important

Cooking ability: Very Important Neutral Not Relevant Not Important

Ability to drive: Very Important Neutral Not Relevant Not Important

General housekeeping: Very Important Neutral Not Relevant Not Important

Are you available to interview the applicant in your home: Yes No

If not, please explain an appropriate venue for an interview:

Will you pay travel expense during the interview process? Yes No

If yes, please specify any limitations:

May applicant contact your current or previous nanny? Yes No

Terms of Employment:

How many hours is nanny expected to work?

Daily work hours?

List any days off during the week:

List any holidays off:

How often will you need nanny to travel with you?

Please approximate starting salary for nanny (gross/net):

If part time, please list hourly rate:

Please indicate YES NO or UNDECIDED as the following apply to nanny:

Paid holidays: Yes No Undecided   Overtime Pay: Yes No Undecided

Paid personal days: Yes No Undecided   Mileage Allowance: Yes No Undecided

Car insurance paid: Yes No Undecided    Use of car on duty: Yes No Undecided

Health insurance paid: Yes No Undecided   Paid vacation: Yes No Undecided

Taxes taken out and paid quarterly: Yes No Undecided

Accomodations for live-in nanny:

If separate quarters from residence please specify:

For quarters in the home, please check what's included:

Private Room
Sitting Room
Bathroom
Phone in Nanny's Room
T.V. in Nanny's Room

Which rooms of your house will be available to nanny when off duty?

Any additional information?

According to the application material I have read, the above has been completed accurately to the best of my knowledge.

Your Name:

Your Email:

Date: