Nanny Intake Form
About you
Name
*
First Name
Last Name
Age
Current job
*
Current student?
*
Please Select
Yes
No
Marital status
*
Do you have children?
Yes
No
Educational background
*
Please specify high school diploma or GED, and any college degrees.
Contact E-mail
*
example@example.com
Mother language and additional languages
*
Please let us know your first language and if you speak other languages fluently.
Do you smoke, consume marijuana, or vape?
*
Please Select
No to all
Yes, more than one
Yes, more than two
Yes, smoking only
Yes, marijuana only
Yes, vaping only
Do you suffer from any allergies?
*
Food, pets, nature, etc.
Do you have any medical conditions that can affect your ability to handle the demands of a childcare position?
*
If yes, please provide detail.
What are your hobbies and pastimes?
*
Logistics
Have you received the COVID-19 vaccine?
*
Please Select
Yes
No
No, but I am willing to get vaccinated.
If yes, please let us know the date of your last vaccine.
*
If you have not been vaccinated, please write "n/a"
Have you receive tuberculosis testing clearance?
*
Please Select
Yes
No
No, but I am willing to get tested.
Please list your vaccine history
*
Please include dates for any of the following you have received: tetanus-diptheria-pertussis/whooping cough, flu, MMR, chicken pox/varicella, Hepatitis A, Hepatitis B, Meningococcal. If no vaccines, please write "none".
Do you have a valid driver's license?
*
Please Select
Yes
No
Do you have a reliable form of transportation for commuting to work?
*
Please Select
Yes
No
Can include car, public transport, etc.
If you have a car, do you have insurance?
*
Please Select
Yes
No
Are you looking for a position that allows you to bring your child to work?
*
Please Select
Yes
No
Not applicable
Have you worked as a nanny with your own child in a previous role?
*
Please Select
Yes
No
Not applicable
What type of childcare job are you looking for?
*
Part-time, full-time, short-term, long-term, occasional
How far from home would you be prepared to travel to work?
*
Please give an approximate measure in hours or miles.
Would you be willing to travel with us?
*
Please Select
Yes
No
Unsure, more explanation needed.
Availability
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Would you be willing to work occasional weekends?
*
Please Select
No
Yes, not a full day
Yes, a full day
What hours would you like to ideally work?
*
Are your hours flexible?
*
Please Select
Yes
No
Somewhat, more explanation needed.
What is your ideal childcare job?
*
Please include any relevant details including number of children, live-in/live-out situation, age of children, daily activities, etc.
Would you be willing to work occasional date nights?
*
Please Select
Yes
No
Work experience
How many years of experience do you have working with children?
*
What are your formal childcare qualifications?
*
Please include any of the following: CPR, First Aid, water safety training, certificates, classes, degrees, etc.
Experience
*
Newborn
Toddlers (1-3 years)
Infants (up to 1 year)
Twins / Multiples
Children with disabilities
Children 3+ years
Children 5 years and up
Additional skills
Cooking/baking
Crafting
Swimming
Yoga
Gymnastics
Gardening
Other
If you selected "other" please share your additional skills.
Gross salary expectation (hourly)
*
Please list a range of two numbers (x-x) or a set number (x) in USD$
Payment method preference (check, cash, Venmo, etc.)
*
Payment frequency preference (weekly, biweekly, monthly, etc.)
*
Earliest start date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please tell us about your last childcare position
*
Please briefly describe your duties, number of children, ages of children, and live-in/live-out situation.
Did you perform any of the following duties in your role: housework, pet care, and meal preparation?
*
If yes to any, please describe in brief detail. If no, please write "n/a".
Employer's contact number
Please enter a valid phone number.
Format: (000) 000-0000.
Employer's email address
example@example.com
Can we contact this employer for a reference?
*
Please Select
Yes
No
Employer 2 (childcare preferred but not required)
*
Job title
*
Duties
*
Start Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Start / end date
*
Reasons employment ended
Additional information about this position
Employer's contact number
Employer's email address
example@example.com
Can we contact this employer for a reference?
*
Please Select
Yes
No
Employer 3 (optional)
Job title
Duties
Start / end date of employment
Reasons employment ended
Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer's contact number
Please enter a valid phone number.
Format: (000) 000-0000.
Employer's email address
example@example.com
Can we contact this employer for a reference?
Please Select
Yes
No
Additional information
Please use this space for anything else you would like us to know.
Submit
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