Nannies from the Heartland, Inc.

Date:_____________________

FAMILY APPLICATION

FAMILY BACKGROUND

Family Name: ________________________________________ Home Phone:(_____)_________________

Street: ________________________________ City: _____________________ State: ____ Zip:_________

Mother's Name: ____________________ Father's Name: ______________ Both live at this address? ___

Mother's Occupation: _________________________________ Work Phone:(_____)__________________

Email Address:_______________________________________ Fax:(_____)_________________________

Father's Occupation: _________________________________ Work Phone: (_____)__________________

Email Address:_______________________________________ Fax:(_____)_________________________

Children's Names	Gender	Date of Birth	Yr in School

CHILDCARE REQUIREMENTS
Childcare is the nanny's primary responsibility. Please describe in detail the expected duties including childcare:

_______________________________________________________________________________________________

Please describe any other requirements you may have and the type of person you may have in mind (age,
experience, education, special training or skills, etc); Include any special needs of the children:

_______________________________________________________________________________________________

ACCOMMODATIONS & LIFESTYLE
It this Is to be a live-in position, please describe in detail the accommodations you will provide (bedroom size
& location, private or shared bath, TV, furnishings, etc):

_______________________________________________________________________________________________

Please describe your family's leisure time activities and general lifestyle:

_______________________________________________________________________________________________

Please describe any household pets: _________________________________________________________

Do any family members smoke? _______________________

NANNY WORK SCHEDULE, SALARY & BENEFITS

Normal Work Schedule:

	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
Start
End
Total Hrs

Other Hours Required? _____________________________________________________________________

_______________________________________________________________________________________________

Travel with the family (vacations and/or weekends)? ______________________________________________

_______________________________________________________________________________________________

Expected Gross Salary Range ______________________________________

Benefits you are willing to offer/consider (the actual salary/benefits package will be determined between the
family and the nanny):

Paid Vacation?_______________ Paid Holidays? ________________ Paid sick leave?_________________

Car avail (full or part-time)? ___________ Health or Country Club? _________ College courses? _________

Medical Insurance Contribution?___________________Other? _____________________________________

REFERENCES: (please include previous child care providers if possible)

Name:		Address:
Phone: ( )	Times to Call:	Relationship:	How Long?

Name:		Address:
Phone: ( )	Times to Call:	Relationship:	How Long?

Name:		Address:
Phone: ( )	Times to Call:	Relationship:	How Long?

OTHER INFORMATION:

When will you need a nanny to start? _______________ Live in or Live out: ____________________

Is this a short term position (less than 1 year)? ________ If yes, how long? _____________________

Do you require the nanny to have a car? _____________

Do you require the nanny to transport children in her/his own car?______ If yes, how is the nanny compensated for
work related driving?_______________________________

Do you have any additional information or comments that will help us make the most compatible
match for you and the caregiver?

_______________________________________________________________________________________________

Best times and phone number to call you _____________________________________________________

How / Where did you hear of Nannies from the Heartland? _______________________________________

Is all the information on this form true, complete and accurate to the best of your knowledge?_____

Signature: ______________________________________________ Date: ________________________

Nannies from the Heartland, Inc. ** 5490 Balsam Lane No, Minneapolis, MN 55442-1805 ** (763) 550-0219 ** Fax (763) 519-0881

this page was last updated on July 17, 2008