FAMILY APPLICATION FORM

MEET THE PARENTS

Parent 1's First Name

Parent 1's Last Name

Parent 1's Email Address

Parent 1's Phone Number

Parent 1's Occupation

Parent 2's First Name

Parent 2's Last Name

Parent 2's Email Address

Parent 2's Phone Number

Parent 2's Occupation

FAMILY HOME ADDRESS

Street Address

Address Line 2

City

State/ Province

Postal/ Zip Code

MEET THE CHILDREN

Please use the box below and specify Child 1’s Name, Birthdate, Gender (female, male, none binary, or rather not say), and the way you describe your child.

Please use the box below and specify Child 2’s Name, Birthdate, Gender (female, male, none binary, or rather not say), and the way you describe your child.

Please use the box below and specify Child 3’s Name, Birthdate, Gender (female, male, none binary, or rather not say), and the way you describe your child.

Please use the box below and specify Child 4’s Name, Birthdate, Gender (female, male, none binary, or rather not say), and the way you describe your child.

Please use the box below and specify Child 5’s Name, Birthdate, Gender (female, male, none binary, or rather not say), and the way you describe your child.

Please use the box below and specify Child 6’s Name, Birthdate, Gender (female, male, none binary, or rather not say), and the way you describe your child.

POSITION INFORMATION

Please check all of the position types you are looking for. Check all tht apply. Required

Less than 30 hours/week

30 to 40 hours/week

40 Plus hours/week

Live-In

Expected start date:

Do you have any flexibility with the start date?

Yes

No

Please check the houry rate range you are proposing. Required

$16-$22 per hour

$23-$28 per hour

$29+ per hour

Is there a parent at home during the nanny’s working hours?

Yes

No

If yes, please check all that apply.

Stay at Home Parent

Work from Home Parent Full-Time

Work from Home Parent Part-Time

Other

Please explain:

Other than the parents and children, is there anyone else that lives with your family?

Yes

No

SCHEDULE

Please use the spaces below and specify the hours per day that the employee is expected to be at their job.

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Please check all the additional requirements that apply.

Evenings

Weekends

Travel

NANNY RESPONSIBILITIES

What childcare duties nanny will be responsible for?

Please mention all other duties the nanny may be responsible for.

What qualities are you looking for in a nanny?

OTHER INFORMATION

Are there any medical situations, special circumstances, food allergies or dietary practices of which we should be aware in order to facilitate a more appropriate placement?

Yes

No

Will there be any pets in the location of care?

Yes

No

If yes then what kind of pets and for what part of their care is the nanny responsible?

Do you have indoor surveillance cameras?

Yes

No

Will you have any household help other than the nanny?

Yes

No

If yes then please describe additional household help:

Does the nanny need a car to arrive at the family’s home?

Yes

No

Is there parking available for the nanny?

Yes

No

Would you be willing to reimburse the nanny for parking costs?

Yes

No

Will the nanny be required to drive as part of the position?

Yes

No

If yes then briefly describe the nanny's potential driving responsibilities:

Is there a family car available?

Yes

No

REFERENCES

First Name

Last Name

Relationshiop to you

Reference Phone Number

FAMILY AGREEMENT

Agree to our terms: *

I understand that if I hire a candidate that has been presented by Magnolia Academy Nannies and Tutors and/or utilize the screening materials of said candidate, I will be responsible to pay a placement fee to the agency. Upon receipt of my application Magnolia Academy Nannies and Tutors will send me an employer/agency contract, which further explains the payment schedule and replacement policy. Before a search is begun, I agree to return a signed copy of the contract to Magnolia Academy Nannies and Tutors. I have read the agreement above and by entering my initials in the box below, I agree to adhere to it.

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