Client Application

Family Application

This 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:*
- Live-in
- Live-out
- Either
Client Name:*
FirstLast
Email:*
Address:*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal Code
Phone:*
Best Time to Reach You:*

Spouse 1 Name:
FirstLast
Employer:
Business Address:
Street AddressAddress Line 2CityState / Province / RegionZip / Postal Code
Email:
Cell Phone:

Spouse 2 Name:
FirstLast
Employer:
Business Address:
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Email:
Phone:
Does either parent work from home?*
- Yes
- No
Please explain the at home work situation:
Care is for: Name(s), Date of Birth, Relationship*

Caregiver's anticipated START DATE:*
How did you hear about WHITE HOUSE NANNIES, INC.?*
By whom were you referred?
Have you ever used a placement agency before?*
- Yes
- No
Agency Name:
Have you hired a nanny before?*
- Yes
- No
What did you like best about him/her?
What were his/her drawbacks?
What specific skills and abilities are you looking for in a Nanny?*
What is your policy on discipline?

Please describe your family's favorite interests and hobbies: (swimming, music, etc.)*
Will the nanny be required to administer any medications?*
- Yes
- No
Please describe any special needs: (physical disability, behavioral concerns, allergies, etc.)
Are there pets in your home?*
- Yes
- No
Who cares for them?
Describe pets: Dogs? Cats? Others?
Type and description of pet care desired:

If your position is Live-In, please describe the accommodations you will provide for the Nanny:
Are there any special circumstances in your family that would affect the job description for your Nanny?*
What do you anticipate the Nanny's schedule to be? (Please indicate the days of the week and hours to be worked.)*
Do you plan to take your Nanny with you when you travel?*
- Yes
- No
What percentage of the job is childcare?*
What percentage of the job is domestic work?*
Do you have domestic help?*
- Yes
- No
Type of domestic help & frequency:
What household tasks will the Nanny be expected to do?
Is cooking required?*
- Yes
- No
Please explain any dietary restrictions:

Family Application

Step 1 of 7

Electronic Signature: