Child Care Resources for parents of twins, triplets and quads  
 

   


Primary Information:
Last Name: First Name: Middle:
Any Other
Known Names: 		Home Address:
City: State: Zip Code:
What are your major cross streets?
Phone: Home Phone: Cellular Phone: Pager
Social Security Number: Are you eligible to work in the United States?
Would you like to be part of our Nanny Support Group? Email
Address:


Placement Preferences:
Type of position you are seeking (check as many that apply):
Permanent  Full-Time  Days  Weekends  Work around school schedule 
Temporary  Part-Time  Evenings  Live-In  Live-Out 
Weekly Pay Requested? Hourly Rate:
Date you could begin work? Maximum # of children you would care for?
Please check the ages of children you would like to work with: Newborn (0 - 6mos)  Infant (7mos - 1yr) 
Toddler (1 - 2 1/2yrs)  Preschool (2 1/2 - 5 yrs)  School age (6+ yrs)  All of the Above 
If requesting to work with newborns, what experience do you have?
Multiples Experience? (check all that apply): Twins  Triplets  Quads 
Age of children:
Can you swim?   Are you able to travel with the family?
Please check additional tasks that you are willing to do (KEEPING IN MIND THAT THE CHILDREN ARE ALWAYS YOUR FIRST PRIORITY):
Car Pooling  Grocery Shopping  Laundry       Light Housekeeping   Tutoring 
Errands         Cooking                 Sweeping    Dishes                       Feeding Pets 
Pets (How do you feel about animals (like, dislike, fear, allergic):
How did you get your first nanny/sitting job (referral, newspaper, friend, etc):
Have you ever been (or are you currently) a licensed child care provider?
       In what state(s)?
Have you ever had a child care license suspended or revoked? If so, please explain:
Have you ever been convicted of a crime?  
( A conviction will not necessarily disqualify an applicant from employment.) (For purposes of this question, “convicted” includes a plea of guilty, nolo contendre, no contest, or similar plea, participation in a pre-trial diversion or deferred entry of judgment program even if the program was completed and charges were dismissed, bail forfeiture, or verdict or finding of guilt.). If “Yes,” please explain:
Are you CPR certified? (Only answer YES if it is current)
In case of emergency, please contact:   Phone:


Driving:
Do you have a vehicle?
Yes  No 		If yes, Make and Model of vehicle
Tags and Registration Current?
Yes  No 		Driver's License #
Expiration Date:   
State Issued: Auto Insurance Company:
Policy: Agent's name and phone number:
Any drivers license(s) issued in another state(s) in the last 10 years?
Do you have any speeding tickets? If yes, how many and date ticket(s) received:
Any other motor vehicle violations? If yes, please explain:
Have you been in any car accidents? If yes, please explain:
Has your license ever been suspended?
 If yes, please explain:

Personal and Family Background (Optional):
Who do you live with (alone, parent(s), roommate, boyfriend, etc)
Any marriage plans?
Father's Name: Mother's Name:
Father's Business Phone: Mother's Business Phone:
Number and ages of brothers and sisters in your family
Religion? Do you need any time off to attend religious services? If yes, when?
Do you smoke? Would you work in a smoking environment? Yes  No
Do you have any allergies? If yes, to what?
Any dietary restrictions? If yes, to what?
Any visible body piercing or tattoos? If yes, explain?
Do you speak a foreign language? If yes, which ones(s)?
Are you: Single  Married  Divorced  Widowed  Separated 
What is your maiden name?


Indicate Your Interests Below:
Music: Very MuchSome-WhatNot At All
Computers: Very MuchSome-WhatNot At All
Writing: Very MuchSome-WhatNot At All
Sewing: Very MuchSome-WhatNot At All
Movies: Very MuchSome-WhatNot At All
Rollerblading:Very MuchSome-WhatNot At All
Sports: Very MuchSome-WhatNot At All
Piano:Very MuchSome-WhatNot At All
Art: Very MuchSome-WhatNot At All
Reading:Very MuchSome-WhatNot At All
Shopping: Very MuchSome-WhatNot At All
Swimming:Very MuchSome-WhatNot At All
Skiing: Very MuchSome-WhatNot At All
TV:Very MuchSome-WhatNot At All


Nanny Education:
DatesInstitutionCityStateLast Grade
Completed		 Area of StudyDegree
High School:
College:
College:
Trade School :
Other Courses:
Have you taken any Child Development courses:
Have you taken any Education classes?


Permanent Child Care Experience (Please list most recent first):
Start/End Dates Employer & Supervisor Address Daytime Phone # # of Kids / Ages
1.
Reason for leaving: Gross Salary:
2.
Reason for leaving: Gross Salary:
3.
Reason for leaving: Gross Salary:


Babysitting Experience (Please list baby-sitting experience of 3 months or more, NOT including family members):
Dates Parent(s) Name Address Daytime Phone # # of children / ages
1.
2.
3.
4.
5.


Health Information
Do you have any physical restrictions? Yes  No
If yes, please explain:
Are you currently under a physician's care? Yes  No
If yes, please explain:
Have you ever been treated for any of the following? Please check those that pertain to you:
Heart Disease Headaches Cancer Diabetes Hernia
Anorexia High Blood Pressure Chest Pain Aids STD's
If yes, please explain:
Have you ever suffered from any kind of substance abuse? Yes  No
If yes, please explain:
When was your last physical? Date:    Were there any problems? Yes  No
If yes, please explain:

NANNY WRITTEN INTERVIEW
Please answer all of the following questions as completely as possible.
Do not give one word answers!
What did you like most about your mother/father’s parenting skills?
What qualities would you look for if you were hiring a nanny?
What do you see as your personality strengths?
What do you see as your personality weaknesses?
Describe your personality:
Describe your relationship with your family:
What qualities/characteristics are needed to be a successful caregiver of multiples / children?
What experience do you have working with preemies (singles or multiples)?


PERSONAL ESSAY
Why do you feel you would make a good nanny? Please include special skills, activities you like to do, special interests, and details about your personality.


Please answer all of the following questions as completely as possible
1. What types of stimulating activities can you do with a 6 month old to promote growth and development?
2. What are some activities you might do with a two year old?
3. What would you fix a two year old for lunch?
4. What would you do if two children were fighting over the same toy?
5. What would you do if a child felt hot, and seemed sick when he woke up from a nap?
6. What would you say to a six year old who tells you, “You are not my mommy; I don’t have to listen to you”?
7. How would you handle a temper tantrum?
8. How do you handle a child who screams when the parents get ready to leave?
9. List some reasons why a baby might cry.
10. If you can not find anything wrong, what are some ways to soothe a crying baby?
11. Do you have any experience with special needs children? Yes  No
If yes, please describe:
Please describe your child care philosophy regarding discipline. What methods do you use with specific ages?
Toddler:      
Preschool:   
School Age:
13. It is a rainy day and you cannot take your 3 year old to the park. What indoor activities do you do?


To the best of my knowledge, the information on this application is true. I understand that misrepresentation or omission of facts in connection with the information provided may be sufficient cause for dismissal wherever discovered. I permit Minding Multiples, Inc. to show this application and all references to parents as a part of the evaluation process.

I understand that the information on this application has been requested for the purpose of evaluating my qualifications for employment by a family, as a child care provider. I also understand that I am not, and will not be an employee of Minding Multiples, Inc.

I have read and understand the terms and conditions as listed above.
     

 

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