3070 Windward Plaza, Suite. F-352
Alpharetta, GA 30005
Phone: (770) 619-0377 Fax: (770) 619-5777
www.ChildcareResources.com
crinannies@bellsouth.net


Placement Agreement

Click on the Placement Agreement link and:

1). Print and review the Placement Agreement;

    Nanny Placement Agreement (pages 8-11)

 2). Complete it, and sign it;
3). Fill out the form below and submit
4). Bring in the Placement Agreement with you to the scheduled Registration and Orientation Training Class – please call us for details.

Thank you,
Childcare Resources
(770) 619-0377, Ext. 22

NANNY APPLICATION
PLEASE FILL IN ALL APPLICABLE FIELDS.
Date
First Name
Middle Name
Last Name
Maiden Name (if applicable)
Phone    
home                                                 cellular
Fax Number
Email Address
Address
City
State
Zip Code
EMPLOYMENT HISTORY
Do you have at least (2) years of experience in childcare? Yes   No
Please provide your previous employment or positions in childcare for the past four (4) years, and then include all other types of employment.
Please explain any gaps of unemployment.
From

To
Employer
Position
Phone
Supervisor
Reason for leaving
 
From

To
Employer
Position
Phone
Supervisor
Reason for leaving
 
From

To
Employer
Position
Phone
Supervisor
Reason for leaving
 
From

To
Employer
Position
Phone
Supervisor
Reason for leaving
 
From

To
Employer
Position
Phone
Supervisor
Reason for leaving
 
Explanation of employment gaps:
PREFERENCES
Available start date
 Note: This date will become out-dated and change as the referral/placement process continues.
If everything is going well, how long of a commitment are you willing to make to a family?
What would you prefer? Check all that apply.
 Note: Part-time positions are 25 hours and less; Full-time is over 25 and between 40-50 hours per week; Overnight care is a flat (negotiable) rate or fee (depending on the job description). Do not try to negotiate the hours that the family needs (unless they say that it is flexible).		 Live-in        Live-out         Full-time        Part-time             
When are you available? Check all that apply.
 		 Mornings    Evenings       Afternoons      Overnight  Weekends   
Pay range expected
Note: Parents and Nanny, please discuss this salary or hourly pay and the offer during your interview.
Are you negotiable about your pay range?
Areas of preference 1st choice                         2nd choice
    
Would you consider other areas?
 Note: Nanny, please be reminded that in the Atlanta area, most jobs and driving distances are between 30-45 minutes.		 Yes     No
Are you willing to do? Check all that apply. *Click on links for exact definitions.
 
Light housekeeping Housekeeping Care for pets
Light cooking Cooking Errands
Children's laundry Family's laundry Travel with family
   
Drive to:
To and from school
Doctor appointments
Children's activities Grocery store


          

Are you severely allergic to, or afraid of any animals?   If "yes", please describe
Do you speak any foreign languages?
 (Hold down the CTRL key for multiple selections)
Do you swim?
Do you smoke?
Note: Childcare is a NON-smoking industry!
Place of birth
Country  
City
State/Province
TRANSPORTATION
Do you drive and have your own dependable vehicle?
Do you have a valid driver's license, and current auto insurance?
Driver's License Number/State  
Auto Insurance Carrier
Policy Number
Explanation of Transportation. (if applicable)
EDUCATION
High School
Institution Name
City/State  
Graduation Date
College/University
Institution Name
City/State  
Graduation Date
Degree/Certificate obtained
Are you currently a student? Yes   No
Are you willing to schedule your school schedule around work? (if applicable) Yes   No
Please provide us with your current schedule. (if applicable)
 

Day

 Time In Time Out
Monday

AM PM

AM PM
Tuesday

AM PM

AM PM
Wednesday

AM PM

AM PM
Thursday

AM PM

AM PM
Friday

AM PM

AM PM
Saturday

AM PM

AM PM
Sunday

AM PM

AM PM
Are these hours flexible?     Explain
CERTIFICATIONS

Do you need to be certified or re-certified in CPR or First Aid?
Note: You MUST have CPR and First Aid as a CRI requirement.  If you are NOT certified, we will schedule you in the next available class.

    Date Certified (if applicable)
Do you have any other certifications?  
Check all that apply.
 Life Guarding    Swimming    Teaching   Music    Dance   
Other
REFERENCES
References
 Please provide us with the names of two people (not family members) that you have know for at least three years who will be able to describe your character.		     
NAME                                        PHONE (Please include area code and complete phone number.)

    
NAME                                        PHONE (Please include area code and complete phone number.)
QUESTIONNAIRE
1.    Please describe you personality.
       

2.    Why do you want to be a Nanny?
       

3.    What is most important to you in working with a family?
       

4.    Do you consider yourself energetic?  Explain.
       

5.    How many hours of TV do you watch a day, and what TV show(s) do you watch the
       most?   
       

6.    What would you do with school age children during free time?
       

7.    What methods of discipline would you use with a child in your care?
       

8.    What would you do if a child in your care did not come home from school on time?
       

9.    What would you do if a child in your care falls down the stairs and bumps their head?
       
      
       9(a).    Would you allow this child to go to sleep after bumping their head.   
                 Yes    No

10.  What would you do if you were in the mall with a baby and a toddler, and the
        toddler disappears?
       

11. If a child is down for a nap, and continues to cry for over 10 minutes, what would    
       you do?
      

12. What would you do if a child in your care chokes, or swallows medication or
       cleaning supplies?
      

In summary, please describe "extra little" details about your background, personality, and your experience in childcare not previously given in the application.  Please specifically include the following:
   
    1.)    Where you are a native of and list other cities and states that you have lived in and
            when.
   
    2.)    Give brief details about your family, and significant and memorable childhood
            experiences.
   
    3.)    Give significant details about your previous nanny/childcare positions.
   
    4.)    List your future plans and goals, including what you would like to do three to five
           years from now?

      
 
MEDICAL HISTORY
Please answer all questions "YES" or "NO".
 
Yes    No    Back Strain Yes    No    Disc Trouble
Yes    No    Heart Murmur Yes    No    Frequent Fainting
Yes    No    Hearing Problems Yes    No    Disabling Headaches
Yes    No    High Blood Pressure Yes    No    Fatigue/Exhaustion
Yes    No    Tumor or cancer Yes    No    Chronic cough
Yes    No    Rheumatic fever Yes    No    Heart trouble
Yes    No    Kidney trouble Yes    No    Paralysis
Yes    No    Muscle weakness Yes    No    Mental health problems
Yes    No    Problems with legs or feet Yes    No    Dislocated joints
Yes    No    Hepatitis Yes    No    Stomach trouble or ulcers
Yes    No    Alcohol/Substance abuse Yes    No    Anemia
Yes    No    Thyroid problems Yes    No    Bulimia/Eating disorders
Yes    No    Diabetes Yes    No    Asthma or allergies
Yes    No    Arthritis Yes    No    Rheumatism
Yes    No    Convulsions Yes    No    Tuberculosis
Yes    No    Pneumonia Yes    No    Hay Fever
  Yes, Other
Please explain the details for all items to which you have answered "YES".
List all surgery, hospitalizations, serious illness or injuries:
Name of physician
Phone
Are you taking any prescribed medications?     If "Yes" explain
Do you have any partial disability that may limit your work, related to childcare or light housekeeping?     If "Yes" explain
Are you currently covered by health insurance?
If No, are you interested in getting health insurance?

Thank you for your trust and confidence in our service. We appreciate your patronage.

I state that this and all provided information is true and accurate. I understand that I may be terminated from registration or/and employment, if it is determined that I knowingly have withheld pertinent information concerning my health or experience. I authorize Childcare Resources or my respective employer to contact my physician or health care provider for information concerning my health as it relates to my abilities to be employed. I agree to provide references and additional information should it be required.

I have fully reviewed all of the terms of this application and agree to them all.