Nanny Mom Intake Form

Nanny Intake Form
Full Name
Age (must be 18+)
Phone Number
Email Address
example@example.com
Preferred Method of Contact

Phone CallTextEmail
Address or Neighborhood
Do you have a valid drivers license?

YesNo
Do you have reliable transportation?

YesNo
Vehicle make, model and year.
Do you have a clean driving record?

YesNo
If no, explain
Are you willing to transport children?

YesNo
How many years of nanny/childcare experience do you have?
What ages do you have experience caring for? (check all that apply)

Newborns (0-1 month)Infants (2-11 months)Toddlers (1-3 years)Preschool age (4-5)Elementary age (6-11)Teenagers
Do you have experience with special needs?

YesNo
If yes, explain briefly.
Do you have experience with multiples?

NoYes
If yes, explain.
Are you CPR certified?

YesNo but willing to get certified.
Are you First Aid certified?

YesNo but willing to get certified.
What is your highest level of education?
Do you have any other relevant certifications?

NoYes
If yes, explain.
What kind of position are you seeking?

Full-TimePart-TimeTemporary/Short-Term/ContractBabysittingNanny ShareNanny Mom Placement
What is your desired hourly/weekly rate? (its ok to give a range)
Are you comfortable with pets/pet care?

YesNo
if no, explain.
Are you comfortable with light housekeeping/housework?

YesNo
Are you authorized to work in the U.S.?

YesNo
If no, explain.
Do you authorize MamaByrd Nanny Placements LLC to perform a background check on you? (at no cost to you)

YesNo
If no, why?
Write a bio describing your experience (be thorough). What makes you a great nanny? What are some of your interests outside of work?
How did you hear about MamaByrd Nanny Placements LLC? (select all that apply)

InstagramFacebookGoogle SearchAnother agency or caregiverFriendOther
Other
Nanny Mom Intake Form
Child's Name
Child's Age
Describe your child's personality/temperament. What does a typical day look like for them?
What is your preferred parenting style/plan for discipline?
Does your child have any special needs, allergies. or medical concerns?

NoYes
If yes, explain.
Do you plan on bringing your child to work every day?

YesNo
When do you plan/not plan to bring your child?
How many children are you comfortable caring for at once? (including your child)
Are you comfortable hosting other children in your home?

YesNo
How do you plan to balance care between your child and the family's children?
How do you prefer to communicate boundaries with families? (e.g. if your child is sick or if a family's expectations don't feel manageable)
Do you have backup care available in case your child can't attend work?

YesNoSometimes
Sometimes (Explain.)
Thank you for filling out our intake form. We'll review your information and be in touch within 1-2 days to schedule an initial phone interview. MamaByrd supports nanny moms in finding roles that honor both their caregiving strengths and their needs as parents.
Should be Empty:

Nanny Intake Form

Nanny Mom Intake Form