Nanny Application

Please complete the following Nanny application and the Nanny agreement and return them via US Mail to:
P.O. Box 1217
Wainscott, NY 11975
or transmit via fax to: 212 925 5285 with a copy of your driver’s license.

We require a personal profile – on a separate piece of paper, or in an E-mail, please answer the following questions thoughtfully and in enough detail to give us an accurate sense of your personality (2-4 pages).

Please describe your child care experiences and why you want to be a nanny. Why in this location, and what you have to offer the children and family you work for?

Describe your lifestyle and interests.

Have you lived away from home?

Application and Agreement:

Name: _____________________________________________ Date:___________________
Work Phone:___________________________

Home Phone: __________________________

Cell Phone ___________________________ Email address ___________________________

Current address:

Street: ________________________________

City: ___________________________________ State: ________ Zip:___________

Are you at least 18 yrs. old:_______ Social Security #: __________________

Driving/ Personal Habits:

Valid Diver’s License:______ State:______________

License #:____________________________________________________

Number of accidents/moving violations in which you were a driver in the last 3 yrs:___________

Do you drive a stick shift?____ Can you bring a car?_______

Have you ever been convicted of a crime:_________________
If so, explain:____________________________________________

Do you smoke?______
Do you drink alcoholic beverages?___________

Dietary restrictions, if any: __________________________________________________________

Child Care Experience:

Live-in Nanny (y/n):___________
Live-out Nanny (y/n):____________
Mother’s Helper (y/n):_____________

Please describe your experience as a nanny or mother’s helper or babysitter __________________________________________________________________________

__________________________________________________________________________

Cared for nursing baby______ Prepared formula ________ Gave solid foods to baby ______

Provided 24 hr. childcare________ Gave medications ___________

Helped toilet train a toddler________ Taught child to swim________

Cared for ill children__________ Please explain_________________________

Experience with special needs children ________________________

Please explain ________________________________

Student Teaching:_________ Teaching:_________ Camp Counselor:_________ Babysitting:________ Childcare Courses:____________________ CPR:_______

Brought up own children:________ Other:___________

Experience by age of children:

Newborn: ___________ 6-24 months:__________

2-5 yrs.:_________ 6-12 yrs.:___________ Teenagers: ___________

Health:

How is your general health?____________________________________________

What is your energy level?_____________________________________________

Do you take any prescription medications?________ What for?_______________

Allergies:____________ Psychological problems?:_________________________

Are you physically able to do this job?___________________________________

Education and Interests:

Highest level of education:_______________________________________ School/College:____________

Do you swim?____________ How well?_________

Do you like pets?____________

Hobbies:_________________________________________________________________

Special interests:___________________________________________________________

Housekeeping:

General housekeeping:____________ Children’s only:_____________

Cooking ability:____________

Dog walking: ___________________

Past Three Employees:

Start End Family/Company Telephone Reference

________ _______ _________________ _____________ _________________

________ _______ _________________ _____________ _________________

________ _______ _________________ _____________ _________________

Personal References:

Please provide a personal reference who has known you for at least three years. Please do not list a relative:

Name:_______________ Relationship:_____________ Phone:____________

List three childcare references that are not relatives within the past three years:

Name: Phone: Age of Children:
_____________________ _____________________ ____________

_____________________ _____________________ ____________

_____________________ _____________________ ____________

Permanent address:
________________________
________________________
________________________

Permanent phone: __________________________

Authorization:

I __________________________________acknowledge that you have advised me that you may request a reference check which may include information on my character, general reputation, education, personal characteristics, driving record, police record, and past employment. I hereby authorize you to obtain such a report. I acknowledge that I have read and understand this statement and all statements made, and the information provided on the employment application, of which this is a part, are true to the best of my knowledge. I agree to release and promise to hold Nanny Agency of the Hamptons, Inc. harmless for any act of the employer. I also agree to hold Nanny Agency of the Hamptons, Inc. harmless of any claim as a result of the placement.

Applicant’s signature:____________________________Date:_______________

Agreement between (Nanny, herein referred to as “Nanny” or “I”): _____________________ and Nanny Agency of the Hamptons, Inc., a licensed and bonded employment agency in the State of New York.

Nanny Agency of the Hamptons, Inc. is acting solely as a referral agent and at no time will be the d employer. The Nanny is under no obligation to accept any referral to or a job from anyone Nanny Agency of the Hamptons, Inc. refers the Nanny to.

I hereby certify that my claimed identity is genuine and true and I also certify that all the information in the application, essays and additional information given to Nanny Agency of the Hamptons, Inc. by added means is true in all respects.

I hereby relinquish all claims or possible liability from Nanny Agency of the Hamptons, Inc. . At no time will Nanny Agency of the Hamptons, Inc. be held responsible for any damage or loss resulting from employment from a Nanny Agency of the Hamptons, Inc. referral, including any acts of commission or omission on my part or the part of the employer family. I also agree that Nanny Agency of the Hamptons, Inc. will not be held liable for the reimbursement of any fees arising from traveling to or from the set job or any possible court costs or lawyer fees stemming from any claim that may be made by any person.

I understand that I must inform Nanny Agency of the Hamptons, Inc. of any contracts or job offers that may come about in the course of my job search including the acceptance of a position. Nanny Agency of the Hamptons, Inc. is not obligated to find me a position and will not be held responsible if an employment is unsuccessful.

I agree to keep all information given to me about prospective employers confidential and will continue to keep that confidential at all times in respect for the families’ privacy.

I am aware that I am responsible for the travel expenses and travel arrangements to relocate to the said employment and will make my own agreement with my employer for reimbursement or other compensation.

I understand that I am not required to pay a fee of any kind for the referral services of Nanny Agency of the Hamptons, Inc.. I understand that the Nanny Agency of the Hamptons, Inc.’ referral fee is the obligation of my employer. I am aware that there is a contractual agreement between Nanny Agency of the Hamptons, Inc. and my employer and understand that I may not arrive at the employer’s home until such conditions as set in the agreement between Nanny Agency of the Hamptons, Inc. and my employer.

I understand that I am being asked to make at least a ________ month commitment to which ever family I decide to be placed with and am willing to do so. I can start work on this date: ______________ and I must complete work by this date: ______________.

I agree to follow the rules laid down by the American Arbitration Association stating that any problems or breeches of contract arising from this agreement must be settled by arbitration and any judgment made by the arbitrators may be entered in any court having jurisdiction thereof.

I understand that Nanny Agency of the Hamptons, Inc. and my employer will rely on information which I provide on my application, forms provided by Nanny Agency of the Hamptons, Inc. and other records and/or statements which I may provide. I give permission to Nanny Agency of the Hamptons, Inc. and any prospective employer to verify and use the information for employment purposes which I provide during an interview or in writing. I agree that Nanny Agency of the Hamptons, Inc. may cancel its agreement to assist me in finding employment and/or that my employer may dismiss me immediately if any part of the information is not true.

I understand that nothing in this contract is intended to guarantee that Nanny Agency of the Hamptons, Inc. will find me a suitable position. If I accept a position as a result of a referral from Nanny Agency of the Hamptons, Inc. and the job is unsuccessful, I understand that Nanny Agency of the Hamptons, Inc. is not required to assist me in finding another job or to reimburse me for any expenses I may incur should I voluntarily or involuntarily leave my job.

I have read and understand all of the foregoing provisions of this contract and I confirm my agreement with all that is contained in the contract by signing my signature below:

Signature: _______________________________
Date: ______________________