INSTRUCTIONS:

• This may take an hour or more to fill out. Be prepared to fill out this application in its entirety.

• Please be as thorough as possible in each section.

• Make sure you have all phone numbers for references available because this is very important to   include in your application.

• When filling in your answers in a text box, DO NOT hit your 'Enter' or 'Return' keys. Just type as your   text will wrap automatically.

• Your Name, Address, Phone Number, Social Security, and Email Address are required fields.

• Thank you for inquiring with Minding Multiples.

• We are excited for you to become part of our organization!

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? Yes No
Would you like to be part of our Nanny Support Group? Yes No	Email Address:
We offer 24 hour EMERGENCY sick child care services to clients. Would you like to be put on the list to be called offering back up service for sick children ? Yes No

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? Yes No	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? Yes No   Are you able to travel with the family? Yes No
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? Yes No   ( 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) Yes No
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:

Indicate Your Interests Below:

Music:	Very Much	Some-What	Not At All
Computers:	Very Much	Some-What	Not At All
Writing:	Very Much	Some-What	Not At All
Sewing:	Very Much	Some-What	Not At All
Movies:	Very Much	Some-What	Not At All
Rollerblading:	Very Much	Some-What	Not At All
Sports:	Very Much	Some-What	Not At All
Piano:	Very Much	Some-What	Not At All
Art:	Very Much	Some-What	Not At All
Reading:	Very Much	Some-What	Not At All
Shopping:	Very Much	Some-What	Not At All
Swimming:	Very Much	Some-What	Not At All
Skiing:	Very Much	Some-What	Not At All
TV:	Very Much	Some-What	Not At All

Nanny Education:

	Institution	City	State	Last Grade Completed	Area of Study	Degree
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 OR ONE SENTENCE 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:

12. 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.