TSN

Tri-State Nannies

Referral Service

Family Information

General Information

(Please answer all questions and include any helpful, additional information)

Mother’s Full Name ______________________ Occupation __________________________________

Work Address _________________________________ E-Mail Address _________________________

Work Phone _______________________________ Work Fax __________________________________

Father’s Full Name ______________________ Occupation ___________________________________

Work Address _________________________________ E-Mail Address _________________________

Work Phone _______________________________ Work Fax __________________________________

Home Street address___________________________________ City ___________________________

State ________________ Zip ________________ E-Mail Address _____________________________

Home phone: (____)________-______________ Fax:(____)_________-_________________________

How did you hear about Tri-State Nannies? _____________________________________________

Children

Name Age Birthdate Sex

1.______________________________________________________________________________________

2.______________________________________________________________________________________

3.______________________________________________________________________________________

4 ________________________________________________________________________________________________

General Info about your children ___________________________________

A live-in nanny position normally requires a maximum of 40 to 50 hours per week. Some situations require a slightly longer workweek, and, in such circumstances, there should be additional compensation. Tri-State Nannies will not place nannies in positions requiring more than 60 hours per week.

Nanny work hours (Max. Total Work Hrs per Week) ___________

Days to work Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Normal work hours _______ _______ __________ ________ ______ _______ ________

Evenings required _______ _______ ___________ ________ ______ _______ ________

Days off _______ _______ __________ ________ ______ _______ ________

Housekeeping

Do you have housekeeper/cleaning service? _______ How often? _____________________

Housecleaning expected from the nanny? ______________________________________________

_________________________________________________________________________________________

# Rooms in home _____ Square footage ________ Type of home: _______________________

Salary and Benefits

Base salary $_________ per week. Salary review after ________ months. Overtime will

be compensated at $__________ per hour. How long do you want your nanny to stay?

1 year? Less than a year? More than a year?

Starting date: ______________ Ending date (if applicable): _____________________________

# Paid Vacation Days 10 (Standard) _________ Additional Vacation Days _________

# Paid Holidays ____________________________

Nanny Accommodations and Privileges

Separate apartment_____ Separate level from family ______ Private bedroom _________

If bedroom, do family members use this bedroom to access other parts of the house?

________________________________________________________________________________________

Private bath ____________ Shared _________ With whom? ______________________________

Does nanny have access to a telephone? Yes No Separate line? Yes No

If separate line, who will pay basic monthly service charge? Employer? Nanny?

Who will pay for nanny’s long distance calls (either on separate or family line)?

Employer Nanny Comments: __________________________________________________

Live-in nannies provided by TSN need to have regular access to a car during their hours off the job. This is especially important for transportation on evenings and weekends. The optimal situation would be to have a dedicated car for the nanny’s use. However, if a car sharing arrangement is necessary, the nanny should be able to visit friends, go shopping, go to church services and activities, etc., without having to “ask” to use the car every time she goes out.

Is there a dedicated car available for the nanny’s use? Yes No

Is there a car sharing arrangement? Yes No

Because the nanny uses the family’s car, she is covered under the family’s auto insurance policy.

What is your deductible? ______________________________________________________

If the nanny has an accident during child care, the family normally pays for the deductible. However, if the nanny has an accident during personal use, who will pay for the deductible? Employer? Yes No Nanny? Yes No

Other concerns about driving? _________________________________________________________

A television in nanny’s quarters? Yes No VCR? Yes No Cable? Yes No

Can friends visit nanny in her quarters? Yes No Restrictions ___________________

________________________________________________________________________________________

Family Background

Are family members in good health? Yes No If no, please explain ________________

__________________________________________________________________________________________

Has anyone in your home ever been convicted for any offense other than a minor

traffic violation? Yes No If yes, please explain____________________________________

__________________________________________________________________________________________

Have there been any incidences of domestic violence in your family that were reported

to the police or social service agencies? Yes No If yes, please explain: _________

__________________________________________________________________________________________

Are alcoholic beverages consumed in the home? _____ By whom/how much? _________

_________________________________________________________________________________________

Religious affiliation: Jewish Protestant Roman Catholic Other Christian

Other Comments: ___________________________________________________________________

Are there religious events/services which you would want the nanny to attend in caring

for your children? Yes No If yes, explain _______________________________________

________________________________________________________________________________________

Are there religious/life values which you want your nanny to reinforce regardless of

the nanny’s specific religious affiliation? Please specify _____________________________

________________________________________________________________________________________

Any special dietary restrictions for your family? Yes No If yes, please explain.

__________________ ______________________________________________________________________

What pets, if any, do you have in your home? ___________________________________________

Will your nanny have duties related to the care of your pet(s)? __________________________

Do you allow smoking within your home? Yes No Comments:_____________________

________________________________________________________________________________________

Note: Tri-State Nannies only represents non-smoking nannies & only places nannies in smoke-free homes.

Relationship with the Nanny

Who will supervise the nanny? _________________________________________________________

Describe style of supervision ____________________________________________________________

____________________________________________________________________________________________

Hobbies/Interests/Leisure Activities

Indicate hobbies, leisure activities or vacation plans that could impact your nanny’s

schedule or responsibilities____________________________________________________________

________________________________________________________________________________________

References:

Please list one or two individuals who know you well and who could serve as general references for potential nannies. (We encourage nannies to contact the family’s references before accepting a position.)

Name

Address

Telephone (starting with area code)

How do you know this person?

Please list one or two former childcare providers (including any former nannies) who could serve as references for potential nannies. (Again we encourage nannies to contact the family’s former childcare providers before accepting a position.)

Name

Address

Telephone (starting with area code)

How long did this person work for you and why did she/he leave?

Qualifications of the Nanny

Gender Preference: Nanny must be 1) female 2) male 3) Either acceptable

Indicate any other qualities that you consider very important in the nanny who serves your family. Please provide as detailed a behavioral description as possible.

________________________________________________________________________________________

I hereby warrant that the facts presented in this application are true and complete and are made for the sole purpose of assisting me in obtaining the services of a nanny. I authorize Tri-State Nannies to contact the references I have listed for information related to the employment I am offering. I understand that Tri-State Nannies acts as a referral source only in locating prospective nannies and is not a party to any subsequent agreement entered into between me and a nanny referred by Tri-State Nannies. I understand that once the nanny applicant provided by Tri-State Nannies has accepted our job offer and started her job, Tri-State Nannies has completed its services and fully earned its referral fee.

Employer’s Signature: ___________________________________ Date: ___________________

Please return completed form to

Tri-State Nannies

5 Cannon Brook Lane

Norwalk, CT 06851

or fax to (203) 849-9338.

Thank you for letting us serve you!