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VILLAGE NANNIES APPLICATION FORM DATE: GENERAL INFORMATION Name: Address: Home Phone: Work Phone: Cell Phone: Email Address: Date of Birth: Social Security /Social Insurance : DRIVING RECORD Do you have a valid driver s license Yes No License : State/Province: Number of accidents/moving violations in which you were a driver in the past 3 years: Explain: Are you able to drive a manual transmission Yes No Do you have your own car Yes No MISCELLANEOUS Have you ever been convicted of a crime Yes No If Yes, explain: Do you smoke Yes No Do you take drugs Yes No Do you drink alcoholic beverages Yes No MEDICAL HISTORY Do you have any dietary restrictions Yes No If Yes, explain: Do you have any medical conditions that may affect your ability to work as a nanny Yes No If Yes, explain: What is your energy level Are you physically able to work as a nanny Yes No Do you have any allergies Yes No If Yes, explain: Do you take any prescription medications Yes No If Yes, list: Have you had or do you currently have any psychological problems Yes No If Yes, explain: EDUCATION What is your highest level of education School/College/University: Do you have First Aid/CPR certification Yes No If Yes, what level Have you taken any additional courses or training Yes No If Yes, list: INTERESTS Hobbies: Sports: Do you like pets Yes No Explain: Do you do housekeeping Yes No Explain: Do you cook Yes No Explain: List any other interests that may be relevant: EMPLOYMENT HISTORY Dates Employer Telephone Number Duties NANNY EXPERIENCE What is your previous nanny experience Live-in Nanny Live-out Nanny Mother s Helper Other: Describe your experience as a nanny/ mother s helper/babysitter: What is your previous experience working with children Teacher Teacher s Aid Camp Counselor Babysitter Raised your own children Other: What skills