Employer's Application For Long-Term Childcare

White House NanniesThis application is for Permanent Placement Only. To access our Temporary Division Application please contact the office directly.

Submission of this application does not guarantee acceptance.

A NON-REFUNDABLE $300.00 fee will be required once the Employer's Application for Long-Term Childcare is approved by the agency.

Choose one only:        
Live-In Live-Out Either

Date Completed:

1. Client Name(s):*

Email:*

2. Client Home Address:*
Street:
City:
State:
Zip Code:

3. Home Phone:* Best time to reach you during the day?

4. (Spouse1): Employer:

Business Address
Street: City:
State: Zip Code:
Work Phone: Work Fax:
Cell Phone: E-mail:

5. (Spouse2): Employer:
Business Address
Street:
City:
State:
Zip Code:
Work Phone:
 Work Fax:
Cell Phone:
E-mail:

6. Does either parent work from home?*
Yes
No
7. Please explain the at home/work situation:

8. Care is for:*
Child's Name DOB-mm/dd/yy Relationship
Child's Name DOB-mm/dd/yy Relationship
Child's Name DOB-mm/dd/yy Relationship
Child's Name DOB-mm/dd/yy Relationship
Child's Name DOB-mm/dd/yy Relationship

9. Caregiver's anticipated START DATE:*

10. How did you hear about WHITE HOUSE NANNIES, Inc.?*

11. By whom were you referred?

12. Have you ever used a placement agency before?
Yes
No
Agency Name:

13. Have you had a nanny before?*
Yes
No

14. What did you like best about him/her?*

15. What were his/her drawbacks?*

16. What specific skills and abilities are you looking for in a Nanny?*

17. What is your policy on discipline?

18. Please describe your family's favorite interests and hobbies: (swimming, music, etc.)

19. Will the nanny be required to administer any medications? Yes No

20. Special Needs? (i.e. physical disability, behavioral concerns, allergies, etc.)

21. Are there pets in your home?* Yes No
Who cares for them?

22. Describe pets: Dogs? Cats? Others?

23. Type and description of pet care desired:

24. If your position is Live-In, please describe the accommodations you will provide for the Nanny:*



25. Are there any special circumstances in your family that would affect the job description for your Nanny?* Yes No


Please explain:


26. What do you anticipate the Nanny's schedule to be? (Please indicate the days of the week and hours to be worked.)*
  Start   Finish
Monday:
 to
Tuesday:
 to
Wednesday:
 to
Thursday:
 to
Friday
 to

27. Do you plan to take your Nanny with you when you travel?*
Yes
No

28. What percentage of the job is childcare?* What percentage of the job is domestic work?

29. Do you have domestic help?*
Yes
No

30. Type of domestic help & frequency:

31. What household tasks will the Nanny be expected to do?

32. Is cooking required?*
Yes
No
 Are there any dietary restrictions?
Yes
No
Please explain:

33. Will driving be required as part of the Nanny's job?*
Yes
No
Will a car be provided?
Yes
No

34. Will a car be provided for the Nanny's personal use?
Yes
No
Is the car:
Automatic
Manual

35. What is the weekly gross salary range you are prepared to pay your Nanny?

36. List any benefits you will provide the nanny: (car, health insurance, tuition, etc.)

37. Would you be interested in receiving information regarding "nanny taxes" from a payroll professional?
Yes
 No

38. Please include all other pertinent information or comments regarding the position. (long stay guests, home under construction, moving, etc.)


Electronic Signature: By selecting submit, you hereby verify that the above information is accurate. If not, please select cancel.