We would appreciate it if you would take a few moments to answer the following questions. Please be assured that we do not share or sell personal information.

Address Line 1

Address Line 2

City

State

Zip Code

E-mail Address

Home Phone

Bold = Required field

Father's Name

Mother's Name

Father's Employer

Mother's Employer

Father's Business Phone

Mother's Business Phone

Part of Town

How Did You Hear About Nanny Placement Service?

When Do You Need A Nanny Or Care Provider?

Please Choose Appropriate Care Needs

1st Child's Name

1st Child's Age

Sex of 1st Child

2nd Child's Name

2nd Child's Age

Sex of 2nd Child

3rd Child's Name

2nd Child's Age

Sex of 3rd Child

4th Child's Name

4th Child's Age

Sex of 4th Child

5th Child's Name

5th Child's Age

Sex of 5th Child

6th Child's Name

6th Child's Age

Sex of 6th Child

Describe Children's Health

Briefly Describe Children's Personalities (shy, outgoing, well-rounded)

Describe The Type & Hours of School Attendance

Describe Your Approach to Child Rearing & Discipline

Describe A Typical Schedule You Would Expect A Caregiver To Follow

Any Other Adults In The Home Other Than Parents?

What Other Household Staff Do You Employ?

Religion (if appropriate)

Do You Have Any Pets?

Is Smoking Permitted In Your House?

Is Alcohol Permitted In Your House?

Experience With Children

What Is Your Policy For The Nanny Regarding Smoking & Alcohol Consumption In Your Home During Off-Duty Hours?

Please Describe The Rhythm Of The Household, Formal/Informal/Busy, etc.

Please Describe The Community In Which You Reside Including Any Public Transportation From Your Home and Nearest Town Or City

Communication Skills

Athletic Skills

Writing  Skills

Creativity

Laundry Skills

Neat Appearance

Education

Compatible Personality

Music Skills

Organizational Skills

Cooking Ability

Able To Drive

General Housekeeping

Is It Convenient To Interview Applicant At Your Home?

If Not, Please Explain The Most Appropriate Place For Your Interview

Will You Pay Travel Expenses Incurred During The Interview Process?

If Yes, Please Specify Any Limitations

May Applicant Speak To Your Current Or Previous Nanny?

If Hiring Involves Relocation, What Costs Will You Pay?

How Many Hours Is The Nanny Expected To Work?

Daily Hours:   from

to

or

List Any Off Days During The Week

Mon

Tue

Wed

Thu

Fri

Sat

Sun

List Any Holidays Off

How Often Will You Need Nanny To Travel With You?

Please Approximate The Starting Salary For Nanny (gross/net)

If Part-Time, Please List Hourly Rate

Paid Holidays

Paid Personal Days

Car Insurance Paid

Health Insurance Paid

Taxes Taken Out & Paid Quarterly

Overtime Pay

Mileage Allowance

Use Of Car On Duty

Paid Vacation

If Separate Quarters From The Home, Please Specify

For Quarters In The Home, Please Check What Is Included

Private Room

Sitting Room

Bathroom

Phone In Nanny's Room

TV In Nanny's Room

Which Rooms Will Be Available To Nanny When Off Duty?

Any Additional Information?

Your Name

Your Email

Date

This Agreement is made and entered into on

by and between Nanny Placement Service, Inc., and

By signature below, I/we agree and understand that:

1. Nanny Placement Service, Inc. will undertake a search for prospective applicants and refer to me/us those applicants who are interested in the position.  This search shall include the names, addresses, and biographical information of the applicants who appear to satisfy my/our requirements.  Although the applicants have been screened by Nanny Placement Service, Inc., it is my/our ultimate responsibility to decide if a particular applicant meets my/our criteria and to seek out additional information about the applicant if it is needed to arrive at my/our decision.  I/We understand that applicant’s information is strictly confidential and will be used only for the purpose of this agreement.
 
2. A Retainer Fee in the amount of One Hundred ($100.00 plus tax) Dollars is required at the time of the execution of this AGREEMENT for services rendered by Nanny Placement Service, Inc.  This Retainer Fee is applied to the total compensation for those applicable to be paid to Nanny Placement Service, Inc., upon final agreement of employment.  This Retainer Fee is used to cover expenses incurred in checking backgrounds and obtaining criminal and motor vehicle reports of prospective applicants.
 
3. Nanny Placement Service, Inc. shall not be liable for any act or omission by any applicant ultimately chosen by me/us for nanny services.  I/We expressly agree to hold Nanny Placement Service, Inc. harmless for any individual act(s) on the part of the provider placed with me/us.  I/We understand that Nanny Placement Service, Inc. is making no representations and is providing no warranties as to the fitness, ability, or character of any prospective provider.  I/We waive any claim which I/we may have against Nanny Placement Service, Inc. either now or in the future for any acts of the provider which is ultimately chosen by me/us.
 
4. The total Placement Fee for services is earned when a Nanny Placement Service, Inc. referral results, either directly or indirectly, in the employment of an applicant within one year from the initial date of referral.  The entire balance of the Placement Fee, after applicable credit for the initial Retainer Fee, is due and payable three (3) days prior to the employment starting date of the Caregiver.
 
5. If employment is terminated by either the employee or me/us within eight (8) weeks of the starting date, Nanny Placement Service, Inc. will, if I/we choose, provide its services for another referral at no additional charge.
 
6.Nanny Placement Service, Inc. shall have the right to release information submitted in my/our Placement Order to applicants for regulatory and governmental compliance purposes.
 
This Agreement shall be governed by and construed in accordance with the laws of the State of Ohio, unless specifically noted otherwise.  By signature below I/we further acknowledge that I have read and understand the terms of this Agreement and agree to be bound by its terms.  I/We further acknowledge receipt of a copy of this Agreement.

Client

Date

Client

Date

If Yes, Please Describe