Nannies Of Green Hills

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Application For Placement
(Required Fields marked with *)
Today's Date: 
*First Name:  
*Last Name: 
Previous Names:  
Social Security #: 
Date of Birth:  
 
CONTACT INFORMATION
Home Phone: 
Cell Phone: 
Work Phone: 
Pager: 
Alt. Phone: 
*Email: 
Address:  
Address Cont.:  
City: 
State:  
Zip:  
How Long at this address: 
Previous Address: 
Previous City: 
Previous State:  
Previous Zip:  
How Long at this address: 
Parents Address: 
Parents City: 
Parents State:  
Parents Zip:  
Phone of Nearest Relative: 
 
PERSONAL/LEGAL INFORMATION
Current Employer: 
If in school, give your major and projected graduation date: 
Sex:  Female Male
Marrital Status:  Single Married
Widowed Divorced
Number and ages of your childred: 
Number and ages of your grandchildren: 
Are you a citizen of the United States?  Yes No
Are our parent's married?  Yes No
What do your parents do for a living?  
What are the names and ages of your brothers and sisters? 
What is your relationship like with your siblings?
Have you ever been arrested or questions by the police?  Yes No
If yes, please explain: 
Have you or someone you know ever been charged or convicted of a felony or misdemeanor? Yes No
   
Experience
Please indicate all areas which you have experience:
Newborn
Twins/Triplets
Driving children
premature newborn
Potty training
Housekeeping
Housesitting
Traveling
CPR
Foreign Language
Drug abuse/suicide/mental disorders
Teaching
   
EDUCATION
High School Attended: 
Location: 
Graduated:  Yes No
Date: 
College Attened: 
Location: 
Degree obtained: 
Date: 
Additional Training: 
CPR Certified:  Yes No
Date: 
 
MEDICAL INFORMATION
Do you have health insurance:  Yes No
What company: 
Are you currently on any medications:  Yes No
If yes, describe: 
Do you smoke?  Yes No
Have you smoked in the past?  Yes No
Do you have any pet allergies?  Yes No
Have you had any serious accidents, illness or surgeries in the last five years?  Yes No
If yes, please describe: 
Have you in the past, or are you currently being treated for:  Epilepsy/Seizures/Convulsions
 Mental illness/Depression/Moodiness
 High Blood Pressure
Diabetes
Suicide
 Dizziness/Fatigue/Black outs/Fainting
 Fibro Mialgia/Chronic Fatigue Syndrome
 Weight control
Allergies
Visual/Auditory/Vocal impairment?
Physical handicap
Migraines/Headaches
Back Problems/Back Injury
What was the date and reason for your last doctor visit? 
What is the name, address and phone number of your primary care physician: 
   
PLACEMENT PREFERENCE
Please indicate the areas which you are applying for:  Childcare
Temporary Care
Mother’s Helper
Elder/Companion Care
Housekeeping
Can you commit to a year of employment?  Yes No
If no, how long of a commitment could you make to a family? 
Are you willing to do light housekeeping? Yes No
Are you willing to do some light cooking? Yes No
Please indicate the times which you are available:
Morning (7am - 12pm) Sun Mon Tues Wed
Thu Fri Sat
Afternoon (1pm - 6pm) Sun Mon Tues Wed
Thu Fri Sat
Evening (6pm-10pm) Sun Mon Tues Wed
Thu Fri Sat
Overnights (24 hours) Sun Mon Tues Wed
Thu Fri Sat
What are your salary expectations:
 
CHILDCARE REFERENCES
Name:
Phone number:
   
Name:
Phone number:
 
Name:
Phone number:
 
Name:
Phone number:
 
Name:
Phone number:
   
PERSONAL REFERENCES
Name: 
Phone number: 
   
Name: 
Phone number: 
   
Name: 
Phone number: 
   
CAREGIVER SCENARIOS
One of the children that you are watching is doing something wrong. You have already asked him/her three times not to do it. What would you do now?
It’s a rainy day. The children, who are 1 and 4 years old, want to play outside, but it is too cold and wet. You must keep them inside for the entire day. What would you do to keep them busy?
You need to go grocery shopping. You get the children in the car. The youngest has been ill and didn’t sleep very well the previous night. On the way to the store, he falls asleep in the car. You really don’t want to wake him. What do you do?
The parents go out for the evening and you are babysitting. The children are asleep and it is late. You are watching TV. You hear a frantic knock at the front door. By the time you get to the door, the person is pounding on the door saying, “I’ve been hurt in an auto accident. I’m hurt and bleeding. Please let me in and help me. Can I use your phone?” What would you do?
One of your family members calls and is ill and needs you. You are in charge of the children and the parents are at work? What do you do?
You are babysitting and expect the parents to call and give you the telephone number where they can be reached. You are bathing the children, ages 1 and 4. The phone rings and it is in the next room. What do you do?
What signs identify child abuse?
What do you typically do while the children you are watching are taking a nap?
Why would you be the best nanny a family has ever had?
PERSONAL QUESTIONS
If you could have one wish, what would it be?
What do you like best about yourself?
What would you change or improve about yourself?
What is the worst situation you have encountered while caring for children?
What was the best situation you’ve encountered while caring for children?
When did you decide you wanted to be a nanny?
What do you think an employer would most appreciate about you?
Please describe your highest moment in life.
Please describe your lowest moment in life.
What would you want a parent to know about you?
What do you hold as priority in your life?
What are your hobbies?
Driver’s License Number:
Issuing State:
Expiration Date:
List any restrictions on your license:
Yes No
Type of Car
Who is your auto insurance carrier?
Have you had any tickets or accidents within the last year?
Yes No
If so, please explain:


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