Family Application and Agreement

Please fill out the application completely and to the best of your ability.
Family Application and Agreement

29 Route 37 Center, Suite12, Sherman, CT 06784 4320 Boston Post Road, Suite 129, Darien, CT 06820
Family Name:*

Parent #1 First NameParent #1 Last Name
Family Name:

Parent #2 First NameParent #2 Last Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Parent #1 Cell*

Area CodePhone Number
Parent #2 Cell

Area CodePhone Number
Parent #1 Email*
example@example.com
Parent #2 Email
example@example.com
Parent #1 Occupation
Parent #2 Occupation
PLACEMENT
NannyNewborn Care SpecialistHousekeeperPart TimeFull TimeLive InLive OutSummerTemporary
DAYS/HOURS NEEDED (from start to finish)
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

If this is a live-in position, what are the accommodations?   Please explain

Start Date Requested:   Date   Hourly Rate Offered:   Amount
Do you require a Nanny who has been vaccinated for COVID?   Yes or No
We pride ourselves in providing you the best nannies in your area. That being said, to attract and retain the best Nanny for your family, we ask our families to provide their Nanny the following in regard to benefits. Please initial below that you are able to provide the following (If you have any questions, please add a ? or leave a blank, and we will review them.):

Type a label  Two weeks paid vacation (minimum).
Add Initials  Five days paid sick leave (or more).
Add Initials  All major holidays paid.
Add Initials The family will provide a car for the Nanny to use while working.
Add Initials  Any time that your Nanny is available to work her scheduled hours, but the family does not need her, she will be paid for that time.
We refer nannies to you who will be, if hired by you, your employee. Please initial here indicating you understand that we are not the employer of the Nanny.
Add Initials

Rows	Yes	No
Do you have pets?
Caring for pets?

Terms Agreed by:
Client Signature* Date Date
Privacy Policy (SMS Statement):

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.

Jane Thielen

The Impeccable Nanny Agency
Should be Empty:

Rows	Yes	No
Does anyone in your household have allergies?
Does anyone in your household smoke?
Will you require swim supervision?
Will they be required to drive?
Will you be providing a vehicle?
Will you require help with meal preparation?
Will you require the Nanny to cook?
For children?
For family?
Do you have special dietary needs?

Rows	Yes	No
Laundry for children
Laundry for family
Errands
Grocery shopping
Appointments for household