Caregiver/Nanny Form

* = Required Information

Contact Information

First Name *

Last Name *

Address

Street Address *

City *

State / Province *

Postal / Zip Code *

Main Contact Number

Area Code *

Phone Number *

Other Contact Number

Area Code

Phone Number

Is this your mobile number?

Yes

Email Address *

Skype ID

Start Date

End Date

Birth Date *

Do you have a driver license? *

Yes

Driver's License Number

This is for your required driving record check

Have you tested positive for COVID-19? *

Yes

I have NOT been tested

What precautionary measures do you take to protect yourself and others from COVID - 19? (Please leave as much detail as possible)*

Will you take a COVID-19 test if required before starting a Nanny job if the family asks? *

Yes

Can you commit to working at least one year with a family? *

Yes

Have you ever been arrested? *

Yes

In the event of an emergency, are you able to swim? *

Yes

Do you smoke? *

Yes

Do you speak any languages other than English? *

Yes

Are you physically able to climb stairs throughout the day and chase after small children without any difficulty? *

Yes

Do you have children?*

Yes

Do you have a minimum of 3 years paid experience working as a childcare provider? *

Yes

Do you have paid experience working with infants? *

Yes

Do you have experience working with special needs children? *

Yes

Please list any experience that you may have with special needs children.

I am

Willing to work in a home with pets.	Able to prepare basic meals.
Able to travel with a family.	Available to work occasional overnights.
Comfortable working with infants.	None of the above

CPR Certified *

Yes

Expired

Expiration Date

First Aid Certified *

Yes

Expired

Expiration Date

Education History

Highschool *

Did you graduate? *

Yes

Date of Graduation

Did you attend College? *

Yes

College

Date of Graduation

Degree

Do you have additional Education to add?

Yes

College

Date of Graduation

Degree

Employment History

Employer 1

Employer's Name

First Name *

Last Name *

Employer's Address

Street Address *

City *

State / Province *

Employer's Contact Number

Area Code *

Phone Number *

Your Job Title *

Start Date *

End Date *

Number of Children *

Ages of children when you started (Example: 4 years, 7 years)*

Salary *

List any responsibilities that you had *

Reason for leaving *

May we contact this employer as a reference check? *

Yes

Employer 2

Employer's Name

First Name

Last Name

Employer's Address

Street Address

City

State / Province

Employer's Contact Number

Area Code

Phone Number

Your Job Title

Start Date

End Date

Number of Children

Ages of children when you started

Salary

List any responsibilities that you had

Reason for leaving

May we contact this employer as a reference check?

Yes

Employer 3

Employer's Name

First Name

Last Name

Employer's Address

Street Address

City

State / Province

Employer's Contact Number

Area Code

Phone Number

Your Job Title

Start Date

End Date

Number of Children

Ages of children when you started

Salary

List any responsibilities that you had

Reason for leaving

May we contact this employer as a reference check?

Yes

Final Questions

Please answer each question as best you can. The more detail involved, the better idea the families will have of you!

Briefly describe why you enjoy being a nanny *

Briefly, sum up what you have been doing for the last 3 years in your career *

List one positive memory that you have from working as a caregiver/nanny *

Describe your beliefs about disciplining children *

Describe your personality *

Describe your hobbies and interests *

Describe your childhood and how you were raised *

Tell us what you think makes a great caregiver/nanny *

List anything else that you would like the family to know about *

How did you hear about AG EUNICE INTERNATIONAL CARE AGENCY *

Is there a particular listed position you are interested in? *

Yes

Please list the name of the town for that job

By checking the 'Yes' box below, you are verifying that you are legally authorized to work in the United States. *

Yes

By checking the 'Yes' box below, you are verifying that you are agreeing to a background and driving record check *

Yes

By checking the 'Yes' box below, you are verifying that you are agreeing to commit to a minimum of one year/two years with a family if you are placed *

Yes

File Upload

Photo
Upload a Photo
Limited to (2) photos; please make sure the photo is labeled as your name

Nanny Resume
Upload a File/Resume
Please make sure the file name is your first and last name

Please review your application and make sure that all of your information is correct before applying