Client Application Form

In order to submit this application, your name and e-mail address are required fields.

 Date:
* Name:
 Street Address:
 City:
 State:
* Zip:
* E-mail:
 Home Phone:
* Cell Phone:
 Fax:
* Job Preference:
  
  
 Do you require primarily a (select all that apply):
   
   
List Work Schedule Days/Hours:
 Monday:
 Monday Hours :
 Tuesday:
 Tuesday Hours:
 Wednesday:
 Wednesday Hours:
 Thursday:
 Thursday Hours:
 Friday:
 Friday Hours:
 Saturday:
 Saturday Hours:
 Sunday:
 Sunday Hours:
* Do you require an employee to be fluent in any language?
  
 If yes, what language?
* When do you need the employee to start?
 What length of time do you foresee the need for an employee?
 What characteristics do you want your new employee to possess?
 Are there any other employees in the home?
  
 Child Name (1):
 Gender (1):
  
 Age (1):
 Child Name (2):
 Gender (2):
  
 Age (2):
 Child Name (3):
 Gender (3):
  
 Age (3):
 Child Name (4):
 Gender (4):
  
 Age (4):
 Elderly Name (1):
 Gender (1) :
  
 Age (1):
 Are your children in school?
  
 If so, how many days/hours per week?
 Are there any health problems or handicaps?
  
 Do you require the employee to be CPR and/or First Aid certified?
  
 If yes, would you be willing to pay for the employee to get certified?
  
 Do you require an employee who is able to drive?
  
 Do you require the employee to transport the children in her vehicle?
  
 Do you have a vehicle that is accessible for the employee's use?
  
 Do you require an employee who is able to swim?
  
 Do you have any animal(s) in your household?
  
 If yes, what kind of animal(s)?
 If yes, please list the employee’s responsibilities with the animal(s)?
 Do you require the employee to cook for the kids?
  
 Do you require the employee to cook for the parents?
  
 Do you observe dietary laws?
  
 If yes, please specify:
 Do you require an employee to wear a uniform?
  
 Do you require an employee to baby-sit in the evenings?
  
 Do you require an employee to iron?
  
 Do you require an employee to clean bathrooms?
  
 Is travel required with the family?
  
 By airplane?
  
 By car?
  
 If yes, where do you typically go?
 What other qualifications do you require?
 Please list any disqualifying factors?
 Do both parents work?
  
 Does anyone in the family smoke?
  
 Is there a separate bedroom for the employee?
  
 Is there a separate bathroom for the employee?
  
 Will the employee have health benefits?
  
 Will you give the employee paid time off?
  
 Will you give the employee paid holidays?
  
 Which ones?
* What is the salary range?
 Available interview times:
* Directions to your house/interview location:
 Location of public transportation:
 How did you learn about Class Act Nannies, LLC?

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