NannyShare Pre-Registration Form

NannyShare Pre-Registration Form

www.rockandrollnannyshare.com
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Child 1 (Date of Birth) *
Child 2 (Date of Birth)
Child 3 (Date of Birth)
Desired Start Date *

As soon as possible Within 2-4 Weeks 1-2 Months 3-4 Months
Distance Willing to Travel *

Within 1 mile from my home Within 2-4 miles from my home Within 5-15 miles from my home
Would you prefer to be placed with family nearby or a family with children of a similar age? *

A Family Nearby A Family with Children of Similar Age No Preference
My child has recently been enrolled in a childcare center.

Yes No
If "Yes", what is the name of that center?
Do your children have any specific requirements for care?
What are you looking for in the NannyShare service?
What is your preferred child group size? *

1 child 2 children 3 children 4 children
If you wish to pair yourself with another family, please identify the name of the family below:
I am interested in being a host location *

Yes No
If possible, and due to our current circumstances/ situation I would like my child's daily interactions to include ...

No limitations, no social distancing Going out in public with suggested protection, trying to social distance, seeing small social network group Very strict, no outside interactions
Are you comfortable in undergoing a Background Record Check (host families only)

Yes No
Are you willing to undergo a virtual home check (host families only)

Yes No
Additional Comments
NannyShare Lead Stage

Pre-Reg Form Complete
Should be Empty: