Families seeking a Nanny Share should print the following document and complete and sign it,


Nanny Brokers Nanny Share Care Application


Nanny ___
Full Time____ Part Time____



Todays Date________ Date Care is needed____________

Family # 1 Name_________________________________________________________

Address_____________________________________________________________

City_____________________________State______________Zip_______________


Closest Major intersection to your home?____________________________________________

________________________________________________________________________________


Contact #'s
Home_____________________Fax_____________
Mom's Cell_________________ Work _________________ Email______________________________
Dad's Cell_________________ Work ________________ Email______________________________

Mother's Profession ______________________________________
Father's Profession ______________________________________


Children's Names & Ages:

1. ________________________________Age____ Sex________
2.________________________________ Age____Sex________
3.________________________________ Age____Sex________
4 .________________________________Age____Sex________
5.________________________________ Age___ Sex________


Any medical conditions or concerns of the children
______________________________________________________


Childcare Hours Needed:

Mon/ Start ________ Finish_______
Tues/ Start _________Finish_______
Wed/Start _________ Finish_______
Thurs/Start ________ Finish_______
Fri/ Start __________ Finish_______
Sat/ Start __________Finish_______
Sun/Start __________Finish_______

Family # 2 Name_________________________________________________________

Address_____________________________________________________________

City_____________________________State______________Zip_______________

Contact #'s
Home_____________________Fax_____________
Mom's Cell_________________ Work _________________ Email______________________________
Dad's Cell_________________ Work ________________ Email______________________________

Mother's Profession ______________________________________
Father's Profession ______________________________________


Children's Names & Ages:

1. ________________________________Age____ Sex________
2.________________________________ Age____Sex________
3.________________________________ Age____Sex________
4 .________________________________Age____Sex________
5.________________________________Age_____Sex________


Any medical conditions or concerns of the children
______________________________________________________






Childcare Hours Needed:

Mon/ Start ________ Finish_______
Tues/ Start _________Finish_______
Wed/Start _________ Finish_______
Thurs/Start ________ Finish_______
Fri/ Start __________ Finish_______
Sat/ Start __________Finish_______
Sun/Start __________Finish_______


*Total hours per week for combined care ___________

Salary offered $____ Per hour
Salary offered $ ______ Per week for ______ Hours (Before Deductions) Yes___ No____
Any Benefits offered? Yes_____ No_______ If Yes describe____________________________
Paid sick Days Yes_____ No_____
Paid Vacation Yes_____ No_____ If Yes how much___________________

Please describe the type person you feel will best work for BOTH Families, (age range , personality
type)
______________________________________________________________________


Please Check all that pertain to your Family needs:

CPR certified____ First Aide ______
Formal Training_____
2 Years childcare experience____
Non smoker____ Non Drinker_______
Age range of care giver______ To_______
Pets in the home?_____
Min one year assignment____










The work schedule will be_______________________________________
Responsibilities will be__________________________________________________


Both Famiiies have read and completed this Family Application Agreement together .
Please elect (1) Parent to act as a contact person for the Agency, as it is impossible for the Agency to
pass information along to all 4 Parents.
We agree that once we select to hire the Nanny we all agree upon, We understand that the Agency
Placement Fee of $1,500.00 will be due to the Agency  BEFORE the applicant begins employment.

All information and Introductions supplied by the Agency are Confidential.
Any passing of information to potential clients, applicants, employees, other agencies or current
employers is strictly forbidden and the Client will be liable for the full agency placement fee. This will
also constitute a breach of contract and will be subject to damages being paid by the Client's to the
Agency .

*Note* It is VERY important to contact the caregivers Nanny Brokers selects for your Family within 24-
48 hours after the contact info has been given to you by the agency. Most caregivers are seeking to
secure IMED employment . They have been told by the agency you will call them within this said time
frame to preform a phone interview, if you do not contact the caregivers within this said time frame
Nanny Brokers can not guarantee these Caregivers will not accept other job offers from other Clients ,
and you could void your Family application with the Agency .

____________________________ Date___________________________________________________
Client # 1 signature

____________________________ Date___________________________________________________
Client # 2 signature

________________________________________ Agency Signature Date _________

** FOR OFFICE USE ONLY**
Nanny Hired:
Date Hired:
Fee's Paid in Full an Documents Returned by Due Date: Yes No
Date Search expires:
Total Placement Fee Charged
Date trial period expires: