Nanny Placement Registration Form
This document is to be used by the family applicant in search of a nanny (part-time or full-time).
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Today's Date *
MM
/
DD
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YYYY
Type nanny of you are requesting *
Required
Parent 1 First and Last Name *
Parent 1 Cell number *
Parent 1 Work Phone
Parent 2 First and Last Name
Parent 2 Cell number
Parent 2 Work Phone
Parent 2 Email Address
Home address (Please include city, state, and zip) *
Preferred Method of Contact *
Required
Number of Children in Home *
Child 1 First and Last Name *
Child 1 Gender *
Child 1 Birthdate *
MM
/
DD
/
YYYY
Please describe child's personality, developmental stage, and interests *
Child 2 First and Last Name
Child 2 Gender
Clear selection
Child 2 Birthdate
MM
/
DD
/
YYYY
Please describe child's personality, developmental stage, and interests
Child 3 First and Last Name
Child 3 Gender
Clear selection
Child 3 Birthdate
MM
/
DD
/
YYYY
Please describe child's personality, developmental stage, and interests
Child 4 First and Last Name
Child 4 Gender
Clear selection
Child 4 Birthdate
MM
/
DD
/
YYYY
Please describe child's personality, developmental stage, and interests
Child 5 First and Last Name
Child 5 Gender
Clear selection
Child 5 Birthdate
MM
/
DD
/
YYYY
Please describe child's personality, developmental stage, and interests
Do any of the children have any allergies? *
If so, please list the allergy along with the child's name.
If there is an Epipen, by initialing this document, I confirm that I will go over the allergies and how to use the Epipen with the nanny. *
Do any of the children have special needs? *
If any of the children have special needs, please explain.
Do you have any pets? *
How many pets do you have?
Are there any special circumstances that we need to be aware of?
Does anyone in your home smoke?
Date in which you need a nanny to begin services *
MM
/
DD
/
YYYY
How long do you anticipate needing a nanny?
What days would you need the nanny? *
Required
What time do you need the nanny to start each day? *
Time
:
What time would the nanny end their day each day? *
Time
:
Are there any unique qualities that you would require of the nanny?
Is transportation of the children expected (please provide details)? *
Is cooking expected (please provide details)? *
Is housekeeping expected (please provide details) *
How did you here about BSCRVA?
Electronic Signature
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