Nanny 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
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.
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