Nanny Poppins, LLC Employment Application

This form does not have spell check. Please make sure you check form for spelling before you submit. Employment History must be completed to be eligable for an interview. Also, please do NOT fill out the application in ALL CAPS.

Application Requirements: You must love children, be a legal to work in the United States, have a valid drivers license, have a minimum of high school diploma, verifiable nanny/baby-sitting/childcare experience. Please call 617-697-0052 to set up an interview.

General Information
Name * First Last
Age *
Birthdate * / MM / DD YYYY
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

PLEASE NOTE: Nanny Poppins, LLC is not affiliated with or a is a franchise of www.nannypoppinz.com.
Phone Number * - (###) - ### ####
Please leave the best number to reach you during the day. A cell phone number is usually preferable.
Social Security Number *

Our website is completely secure, and your social secuirty number will not be used for anything other than the verification of your identity and background check.
Email Address

Please do not use an AOL or Roadrunner account.
Are you a legal citizen of the United States, or do you have a work Visa? You will need to furnish documented proof of this. * Yes No
Federal Law requires everyone to be a legal citizen, permanent resident, or have a work Visa from the United States to be employed anywhere in this country.
Previous Addresses:
Please list previous addresses:
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Driving Information
What is your driver's License number and the state it was issued in? *

You are required to have a valid driver's license and a reliable car to be a nanny through our agency.
Year/Make/Model of Car *
License Plate Number
Insured By
List all states that you have had a driver's license in other than MA.
List any moving violations, citations, or accidents on your driving record. Parking tickets and non-moving violations are not important.
Availability

Please Note: We are aware that availability is subject to change. You must notify us if your availability changes so that we can consider you for appropriate positions. You may notify us at info@nannypoppins.com.
Hours : HH MM AM/PM
to : HH MM AM/PM
Days Monday Tuesday Wednesday Thursday Friday Saturday Sunday All Week
Status Short Term Long Term
Education
Grammar School

Please include the name of your school, town, state, and whether or not you graduated.
High School

Please include the name of your school, town, state, and whether or not you graduated.
College

Please include the name of your school, town, state, and whether or not you graduated.
Major/Minor
Other Information
Why do you want to be a nanny? *
Explain any child care training, degree in detail (workshops, courses). *
Do you have any current or previous certifications/skills (CPR, First Aid, etc.)? *
Other areas of study and/or special certifications or skills? *
Languages studied?
State any organizations that you have been affiliated with and its location. Please include volunteer work, school clubs, and other activities.
Medical Information
State the name of your physician.
Physician phone number. - (###) - ### ####
Date of last physical examination.
May we speak to your physician? (You will need to give a letter of permission for this, if needed). Yes No
Do you have any medical conditions that could impair your ability to be a caregiver? If yes, Explain.
Do you take any prescription medicine that would impair your ability to drive or safely care for children? * Yes No
Do you smoke and/or drink? If so, how often? *
Have you ever abused drugs? * Yes No
Have you ever been convicted of a crime? * Yes No
Are you willing to be drug tested? * Yes No
What hourly wage are you looking for?
Are you willing to negotiate?
What ages do you have the most experience working with?
Are you comfortable with infants?
How many hours are you looking for per week?
Are you willing to work with two families to make that many hours?
Are you willing to make a commitment of one year? If no, how long of a commitment are you willing to make?
How far are you willing to commute w/traffic?
Would you consider a live in nanny situation?
Are you planning on attending school in the next one year? If yes, how will this effect you work as a nanny?
Do you have any situation that could change your availability? If so, explain.
Who can we contact in case of an emergency? First Last
- (###) - ### ####
I understand that I am now under agreement with Nanny Poppins to report ALL phone calls, interviews and jobs that I have been offered by any of the agency's clients, or it's client's friends, neighbors, relatives and associates. This includes all people I have met who I would not have met if I were not affiliated with the agency. I agree not to be employed by any of the above mentioned people unless I have obtained authorization to do so from the agency directly. I understand that the above mentioned people must pay the appropriate fee to the agency in order to employ me and that it is my responsibility to check with the agency to make sure that the fee has been paid. I agree not to refer my friends, relatives and/or affiliates directly to the above mentioned people for employment purposes. I understand that Nanny Poppins acts only as my agent to assist me in finding employment. Nanny Poppins does not charge a fee of any kind to applicants for employment such as myself, and is not considered a direct employer of any kind. I understand that if employment is offered it will be offered by a client of Nanny Poppins and that person(s) would be my direct employer. I hereby state that all of the information provided by me to Nanny Poppins is true. I have thoroughly read my contract with Nanny Poppins and accept its terms. * First Last
Agreement Confirmation * Yes No

Nanny Poppins, LLC Employment Application

Nanny Poppins, LLC Employment Application

General Information

Previous Addresses:

Driving Information

Availability

Education

Other Information

Medical Information