4221 N. Winfield Scott Plaza, Suite 4
Scottsdale, AZ 85251
480-946-3423 Phone
480-945-3693 Fax

FAMILY APPLICATION

Welcome to our new online application!

Once you complete this application, PLEASE PRINT this form from your browser to keep for your own records. We encourage you to call once you send your application to confirm receipt. Once we receive your information electronically, there is no need to mail or fax a print version.

Alternatively, you may also elect to print your completed form and fax it to the number above in lieu of sending it online electronically.

Family Name Date 
Major Crossroads  Email  
Address City/State    Zip 
Daytime Phone  Evening Phone
Mother's Name  Email 
Occupation
Business Numbers  Phone    Fax
Father's Name  Email 
Occupation
Business Numbers  Phone    Fax

Please provide the following information about your children:

Children's NamesAgeM/FDescribe Briefly
1.
2.
3.
4.


Please describe any special needs your children might require:

Is the atmosphere of your home formal, semi-formal, or casual?

Home Office?
Are any adults home during the day?
If yes, who? Mother    Father  Other  
Do you have any pets?  What type?  
Do you have a housekeeper?  How often?  
Will the Nanny need to travel?    How often?  

The Caregiver

Indicate the type of caregiver needed:

 Hours: Comments:

Nanny

 ≥ 17 hours/week

 Newborn Specialist

 ≤ 16 hours/week

 Babysitter

 Date-night Nanny

 After-school Nanny

 Mother's Helper | Personal Assistant

 Household Manager

 Housekeeper

 Non-medical senior caregiver


What type of personality are you looking for in a Nanny? What qualities are most important to you?
Are you open to a Nanny bringing her own child with her?   
Contact Preference. Select one:  
The nanny can contact me between the hours of:     On these days:  
Start date Days Needed Hours Needed 
Salary  Hourly   Weekly   Annually  

Will taxes be deducted from this salary?    Yes  No

(Go to:  http://acaringnanny.com/familyTaxes.shtml for information regarding taxes for household employees.)
Will housekeeping be required of the Nanny?   
If, yes:
Light ( i.e. picking up, dishes, folding laundry, wiping counters etc.)
Heavy ( i.e. bathrooms, floors, vacuuming, dusting, windows, family laundry, meal preparation etc.)
Child-related only (i.e. picking up toys, child's dishes, child's meal preparation, child's laundry, bottles, etc.)


Please describe specifically the childcare & household responsibilities that are required?

Is driving required?

   If yes, weekly mileage? 
Will a car be provided?   (Current mileage reimbursement = 48.5¢ /mile)
Will you be offering any benefits?

If yes, what would you be willing to offer?  (Industry standard: 1-2 weeks paid vacation/sick/personal time off and 6-7 paid holidays for full-time, half that for part time)
 Paid Holidays PTO/ Vacation Health
 401K Tuition Reimbursement Car use

How were you referred to Caring Nannies?

 Personal referral,   Name:  

 Yellow Pages:    Scottsdale     Phoenix     East Valley     Chandler     Other   

 OB/GYN,   Name: 

 Arizona Republic  Multiples Newsletter

 Google  Yahoo!   MSN

 If other, please indicate search engine & search phrase

Are you registered with another agency?  
Please select one charity: See Giving Back for details.