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Raleigh Office Nancy's Nannies, Inc.
 
 
 
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Babysitter Application
E-Mail Address
Name
Permanent Address
City
State
Zip
How long at this address? 
May we call you at work? 
Home Phone
Best time to call
Business Phone
Best time to call
Birthdate
Birthplace
Salary Range
Preferred Age Group
From
To
Date Available to work
Number of Children Prefered
Have you worked with handicapped or special needs children? Yes No
If yes, explain:
Would you work where there are pets? Yes No
If no, reason:
Number years driving
Type car: Year
Do you have car insurance? Yes No
Insurance Company
Religious Affiliation (optional)
EDUCATION
HIGH SCHOOL OR GED
Name and Location of School
Years Attended
Graduation Date
Subjects Studied
GED, Degree or Diploma Rec'd
If not graduated, reason
COLLEGE
Name and Location of School
Years Attended
Graduation Date
Subjects Studied
Degree Rec'd
If not graduated, reason
GRADUATE SCHOOL
Name and Location of School
Years Attended
Graduation Date
Subjects Studied
Degree Rec'd
If not graduated, reason
BUSINESS EXPERIENCE
LAST OR CURRENT EMPLOYER
Employed From   to 
Name and Address of Employer
Tel. #
Supervisor
Salary
Position
Reason for Leaving
PREVIOUS EMPLOYER
Employed From   to 
Name and Address of Employer
Tel. #
Supervisor
Salary
Position
Reason for Leaving
CHILDCARE EXPERIENCE
1.
Name
Telephone (Home)
Address
Telephone (Business)
City
State
Zip
Occupation
Position Held
Dates
From To
Part Time Full Time Occasional
Number of Children
Children's Ages
Reason for Leaving
2.
Name
Telephone (Home)
Address
Telephone (Business)
City
State
Zip
Occupation
Position Held
Dates
From To
Part Time Full Time Occasional
Number of Children
Children's Ages
Reason for Leaving
MEDICAL INFORMATION
Do you have any physical, dietary or emotional limitations which might affect your work? Yes No
If yes, explain
Have you had any surgery or major illness (physical or emotional) in the past three (3) years? Yes No
If yes, explain
Are you now under a Doctor's care or currently taking prescription medication? Yes No
If yes, explain
Do you smoke? Yes No How much?
Do you drink? Yes No How much?
Any allergies? 
Do you have medical insurance? Yes No
Name of insurance company 
Do you now have or have been told that you have any of the following?
If yes, please explain with dates in the box following the question.
YES  NO 
Frequent Headaches, fainting, dizziness
Heart problems, high/low blood pressure
Asthma, allergies
Rheumatic fever or arthritis
Injury to back, neck, spine, disc
Had a Physical Exam, TB Test or Chest X-ray within past 3 years?  Please explain with dates and results.
Received medical treatment for, or been counseled for alcohol and/or drug abuse/addiction?
GENERAL
Do you speak any foreign languages? 
Do you play any musical instruments?
Memberships in clubs, organizations
Special licenses, awards
CPR Certified? Yes No Date
First Aid Certified? Yes No Date
Can you swim? Yes No Explain ability
Have you ever been convicted of a crime? Yes No
If yes, explain with dates
OR Have you ever had a license suspended or revoked? Yes No
If yes, explain with dates
Why are you interested in this position?
What are you future goals and plans?
In an emergency, who should be notified?
Name
Address
Relationship
Telephone (Home) Telephone (Business)
PLEASE READ AND SIGN BELOW
I certify that the facts in my application are true and complete to the best of my knowledge. I understand that is hired, false statements shall be grounds for dismissal.
I authorize Nancy's Nannies, Inc. to check any statements or references on my application and I authorize the release of information by these parties.
I understand and agree that the babysitter position I am applying for requires that I be in good physical and mental health.
   
TYPE YOUR FULL NAME: 
DATE:  Friday, May 09, 2008

THANK YOU FOR REGISTERING WITH NANCY'S NANNIES, INC.

Which office would you like to send this application to?
Morehead City
Raleigh

 
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All rights reserved.
For more information call 1-252-726-6575.