Nanny Info Form Maryland

Name:

Address:

Apt #:

City:

State:

Zip Code:

General Location:

Travel Radius:

Home Phone:

Cell Phone:

E-mail Address:

Do you Drive?

Yes

No

Do you Have your Own Car?

Yes

No

Make & Model:

How many car seats can you safely put in your car?

Driver's License #:

State of Driver's License:

Ages of Children You've Cared For:

Ages of Children You Would Prefer:

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Select those which apply.

(Y=YES, N=NO, D=DEPENDS, S=SOMETIMES)

Do You Smoke:

Y

N

D

S

Special Needs Care:

Y

N

D

S

Prepare Meals:

Y

N

D

S

Work Flexible Hours:

Y

N

D

S

Do Housework:

Y

N

D

S

Take Your Child with You:

Y

N

D

S

Do You Like Pets:

Y

N

D

S

Can You Swim

Y

N

D

S

Infant Experience:

Y

N

D

S

Care for the Elderly:

Y

N

D

S

Select the Types of Jobs You Are Interested In

Specific Days and Hours Needed:

Select those that apply.

Attended High School

High School Graduate

Attended College

College Graduate

Advanced Degree

Nanny School Graduate

Languages Spoken:

Other Childcare Training:

Name of High School:

Dates Attended:

Location of High School:

Year Graduated:

Name of College:

Date Attended:

Location of College:

Year Graduated:

College Field of Study:

Degree Obtained:

Start Date:

End Date:

Salary Requested:

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List below anyone else you know that may be interested in being a nanny.

Name:

Phone #:

Name:

Phone #:

How long could you commit to a family?

How does a childcare job fit into your future?

Are you signed up with any other nanny services?

Yes

No

If yes, which ones, including other ACN offices?

Do you use alcohol, nicotine, or drugs?

Yes

No

If yes, please explain:

List any allergies that might affect your job:

Do you have any physical conditions that might affect your performance as a nanny?

Are you on medication?

Yes

No

If yes, please explain:

Can you obtain a letter of good health from a doctor or a clinic?

Have you ever been convicted of a crime?

Yes

No

If yes, explain the nature of the offense, date & court outcome:

Have you had any speeding tickets, moving violations, accidents, traffic convictions or points on your license within the last 10 years?

Yes

No

If yes, please explain:

Have you ever been dismissed from a job?

Yes

No

If yes, please note: Date:

Employer:

Are you certified in CPR?

Yes

No

If yes, when is the expiration date

Are you certified in First Aid?

Yes

No

If yes, when is the expiration date

Do you have multiples experience?

Yes

No

If yes, what type (twins, triplets, etc.), what age(s) and where was the experience from (day care, private home, etc):

Which of the following duties are you willing to do? Select those that apply.

Person To Contact In Case of Emergency:

Relationship to you:

Phone #:

Nearest Relative NOT Living With You:

Relationship to you:

Phone #:

How did you learn about A Choice Nanny?

Why do you want to become a nanny?

How did you get interested in childcare?

What qualities would make you a good nanny?

What do you feel children like best about you?

What forms of discipline do you use?

We ask that you write a brief autobiography to the families. Please include a description of yourself, your personality, and your family. Please include what you like to do when you are not working (ex. activities, interests, special hobbies, talents, etc.). Please include what your childhood was like, if your mother worked, the number of brothers/sisters you have.

What would you do to keep a toddler busy on a rainy day?

How would you handle a 2-year old's temper tantrum?

How would you handle a 4-year old who spilled their milk?

How would you handle an 8-year old that is being rude & unwilling to do what they are told?

What activities would you plan to do with children of various ages?

What do you believe makes a happy childhood?

What is the best job you have had and why?

Why should a parent hire you?

What kind of family would you like to work for?

What is the hardest or most difficult situation you have had to deal with in your life?

What have you done that you are most proud of in your life?

How do you resolve conflicts with others?

What do you like most about yourself?

What do you like least about yourself?

If a parent comes home late every day, how would you handle it?

If a parent asks you for assistance with something that is not usually in your job description, what would you do?

If a parent tells you that you need to improve on some of your duties, how would you react?

If a parent treats you unfairly, from your point of view, how would you react and how would you handle that situation?

We ask that you write a brief Autobiography to the families about yourself. Please include a description of yourself, your personality, and your family. Please include what you like to do when you are not working (ex. activities, interests, special hobbies, talents, etc.). Please include what your childhood was like, if your mother worked, the number of brothers/sisters you have

Please include a description of your past childcare experience (ex. What type of childcare jobs you have had, what ages you have worked with, a typical day with children etc.)

Which job situation(s) would you feel comfortable with? Select those that apply

Multiples Experience

Multiple Children of Different Ages

Children with Special Needs or Problems

Parent(s) Working at Home

Infants or Newborns

Grandparents at Home

Two Families Sharing You

None of These Situations

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AUTHORIZATION OF RELEASE OF CANDIDATE BACKGROUND INFORMATION

LAST:

FIRST:

MIDDLE:

CITY:

ADDRESS:

APT #:

STATE:

ZIP CODE:

AGE:

BIRTHDATE:

MARITAL STATUS:

YOUR CHILDREN (include DATE OF BIRTH and GENDER):

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LIST ALL ADDRESSES YOU HAVE LIVED AT FOR PAST 7 YEARS

(include temporary addresses, college addresses etc.)

ADDRESS | CITY | STATE | COUNT | YEARS AT ADDRESS

LIST ALL ADDRESSES YOU HAVE LIVED AT FOR PAST 7 YEARS (include temporary addresses, college addresses etc.) ADDRESS | CITY | STATE | COUNT | YEARS AT ADDRESS

DRIVER'S LICENSE NUMBER:

STATE LICENSE ISSUED:

LICENSE EXPIRATION DATE:

LIST COLLEGE(S) ATTENDED or CURRENTLY ATTENDING (include name of college, city, state, dates attended & degree earned)

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MOST RECENT OR CURRENT EMPLOYMENT

COMPANY NAME:

ADDRESS:

SUITE #:

CITY:

STATE:

ZIP CODE:

PHONE #:

SUPERVISOR'S NAME:

JOB TITLE:

DATES OF EMPLOYMENT:

REASON FOR LEAVING:

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I have not withheld any information a reasonable person would expect a prospective nanny to provide. I have been honest in revealing and explaining any undesirable background. I do certify that all information noted here is true to the best of my knowledge. I authorize full disclosure and release to any duly authorized agent of the ACN Referral Center, CSF Inc. and ACN Holding Inc. of all information and records, both public and private, including but not limited to criminal history as required to conduct a complete background investigation. I hereby release all persons and agencies from any liability associated with such disclosure. I understand such information may be duplicated and given to any prospective client seeking to hire me, and I hereby authorize this. I also specifically request that all agencies, representatives and references fully cooperate with this investigation and provide the requested information. A Choice Nanny does not discriminate.

PRINT FULL NAME:

SIGNATURE:

DATE:

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NANNY CANDIDATE (NON-RELATIVE)

REFERENCE INFORMATION

Childcare References

NAME:

HIS/HER PROFESSION:

ADDRESS:

HOME PHONE:

WORK PHONE:

CELL PHONE:

E-MAIL:

RELATIONSHIP TO YOU:

DATES OF EMPLOYMENT:

AGES OF CHILDREN CARED FOR:

JOB RESPONSIBILITIES:

DATE AND REASON FOR LEAVING:

NAME:

HIS/HER PROFESSION:

ADDRESS:

HOME PHONE:

WORK PHONE:

CELL PHONE:

E-MAIL:

RELATIONSHIP TO YOU:

DATES OF EMPLOYMENT:

AGES OF CHILDREN CARED FOR:

JOB RESPONSIBILITIES:

DATE AND REASON FOR LEAVING:

NAME:

HIS/HER PROFESSION:

ADDRESS:

HOME PHONE:

WORK PHONE:

CELL PHONE:

E-MAIL:

RELATIONSHIP TO YOU:

DATES OF EMPLOYMENT:

AGES OF CHILDREN CARED FOR:

JOB RESPONSIBILITIES:

DATE AND REASON FOR LEAVING:

NAME:

HIS/HER PROFESSION:

ADDRESS:

HOME PHONE:

WORK PHONE:

CELL PHONE:

E-MAIL:

RELATIONSHIP TO YOU

DATES OF EMPLOYMENT:

AGES OF CHILDREN CARED FOR:

JOB RESPONSIBILITIES:

DATE AND REASON FOR LEAVING:

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Personal References

NAME:

HIS/HER PROFESSION:

ADDRESS:

WORK PHONE

WORK PHONE:

CELL PHONE:

E-MAIL:

RELATIONSHIP TO YOU:

NAME:

HIS/HER PROFESSION:

ADDRESS

HOME PHONE:

CELL PHONE:

E-MAIL:

RELATIONSHIP TO YOU:

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PREVIOUS EMPLOYMENT

(NON-CHILDCARE)

REASON FOR LEAVING:

COMPANY NAME:

SUITE #:

CITY:

STATE:

ZIP CODE:

PHONE #:

SUPERVISOR'S NAME:

JOB TITLE:

DATES OF EMPLOYMENT:

REASON FOR LEAVING:

COMPANY NAME:

SUITE #:

CITY:

STATE:

ZIP CODE:

PHONE #:

SUPERVISOR'S NAME:

JOB TITLE:

DATES OF EMPLOYMENT:

REASON FOR LEAVING:

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CANDIDATE ACKNOWLEDGMENT AND RELEASE

I acknowledge that I have given information about myself to the A Choice Nanny ("ACN") Referral Center designated below. I understand all ACN Referral Centers, including the ACN Referral Center designated below, any of their directors, officers, shareholders, agents, and employees (collectively the "ACN NETWORK") specialize in referral of dependent care providers for occasional, temporary and permanent on-going care.

In consideration of the services provided through the ACN NETWORK and of the personal benefits and advantages that might be received by me as a result of these services and being fully aware of the potential risks and hazards involved in providing care for a dependent(s), I unconditionally accept and assume any and all risks involved in the position of dependent care provider obtained through the ACN NETWORK's referral.

I exempt and release ACN Holding, Inc., the ACN NETWORK, their directors, officers, shareholders, agents, and employees from all actions, causes of action, claims and demands for injuries, accidents, sickness and amages of any nature, which may happen to me as a result of accepting and performing the position of dependent care provider through the ACN NETWORK's referral.

This release extends and applies to all unknown, unforeseen, unanticipated and unsuspected injuries, damages, losses and liabilities, and the consequences of them, as well as those, which may have been disclosed and presently known to exist. The provisions of any state, federal, local or territorial law or statute providing in substance that releases shall not extend to claims, demands, injuries or damages which are unknown or unsuspected to exist at the time, to the person executing such release, are expressly waived.

I further agree that during the term of my position as dependent care provider and after termination, regardless of the cause of termination, I will not communicate or divulge to, or use for the benefit of, any person(s), partnership, association or corporation any confidential information or know-how concerning the family I work(ed) for or the ACN NETWORK, or the methods of operating the ACN NETWORK centers which may be communicated to me, or of which I may be apprised by virtue of my position as dependent care provider. I understand this also means that I cannot refer any friends, relatives or acquaintances to the family for whom I work or have worked (or to any of their friends, relatives or acquaintances) without first receiving the written approval of the ACN Referral Center designated below. I agree not to compete with the ACN NETWORK within a radius of 10 miles from any ACN Referral Center for a period of no less than 2 years after termination of my employment regardless of the cause.

I also agree to immediately terminate my employment with any client of the ACN NETWORK who does not pay the ACN

NETWORK monies owed due to my employment.

I understand that I may be required to participate in a training course and/or programs as an important part of my qualification as a candidate to be a dependent care provider and which, if required, I hereby agree to complete. I acknowledge that I am not an employee of the ACN NETWORK. I further acknowledge that the ACN NETWORK is not responsible for the conduct of any ACN NETWORK client for whom I may work.

I agree to settle any controversy or claim arising out of or relating to my relationship with the ACN NETWORK by arbitration. Such arbitration shall be conducted in accordance with the rules of the American Arbitration Association, in the office closest to the ACN Referral Center, which referred me, and judgment upon the award rendered by the arbitrators may be entered in any court of competent jurisdiction.

SIGNATURE OF CANDIDATE

PRINT NAME

DATE

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We will contact you shortly for your social security information upon processing.

NANNY INFO FORM

Nanny Info Form