Client E-Mail
Important: Enter a valid e-mail address for correspondence.
E-Mail:
Contact Information
Father`s First/Last Name:
Mother`s First/Last Name:
Address Line 1:
Address Line 2:
City:
State:
Choose a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
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Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Home Phone:
Alternate Phone:
Cell Phone:
Best time to call:
select one
Morning
Afternoon
Evenings
Anytime
Work Information
Father`s Profession:
Company:
Address/Location:
Work Phone:
Are you employed out of the home?
Select Answer
Yes
No
Mother`s Profession:
Company:
Address/Location:
Work Phone:
Are you employed out of the home?
Select Answer
Yes
No
Family Environment
Children`s Names, Ages, Interest:
Please explain if expecting more children within a year:
Any children requiring special care (medications, etc.):
Please describe your lifestyle, interests, hobbies:
List any special religious or dietary observances:
List other family members living at home:
Describe household pets and disposition (friendly, protective, etc.):
Does anyone smoke in the home?
Select Answer
Yes
No
Is smoking allowed in the home?
Select Answer
Yes
No
Describe the type of parent you are (strict, nervous, etc.):
Housekeeping standards and outside cleaning services used:
Explain any incidents of domestic violence:
Explain any family member convicted of felony:
Type of childcare you had in the past:
Describe Nanny`s living arrangements:
Do you need a Driver?
Select Answer
Yes
No
Will a car be provided?
Select Answer
Yes
No
Employment Preferences
Position needed:
Select Answer
Live-In Nanny
Live-In Baby Nurse
Live-In Mother`s Helper
Live-out Nanny
Live-out Baby Nurse
Live-out Mother`s Helper
Work arrangement:
Select Answer
Permanent position
Temporary position
Summer position
When do you need nanny to start?
Age preference of Nanny:
List qualities or skills you prefer (swimming, religion, etc.):
Chores Required of Nanny
Meal preparation - Children:
Select Answer
Yes
No
Meal preparation - Family:
Select Answer
Yes
No
Household / grocery / activities / errands:
Select Answer
Yes
No
Bathing Children:
Select Answer
Yes
No
Changing Diapers:
Select Answer
Yes
No
Children`s Laundry:
Select Answer
Yes
No
Family Laundry:
Select Answer
Yes
No
List any extra duties required or needed (vacuuming, tutoring, etc.):
References
Name:
Relationship:
Phone:
Alternate Phone:
Name:
Relationship:
Phone:
Alternate Phone:
How did you hear about us?
