Family Application - Midwest Nannies, Ltd. Child Care Providers Temporary and Permanent

The Family Application

Please do NOT print out this form,
it is for online submittal only.

Since your privacy is of utmost importance to us, this application form is hosted on a secure server and all data sent to us is encrypted.

Thank you for your interest in Midwest Nannies, Ltd. We are pleased to help you with your child care needs. By completing this Family Application we can begin the process of introducing you to nannies in our pool of candidates. We will also need a signed Referral Agreement to initiate the search. The referral fee for placing a nanny with you is equal to 10% of the nanny’s gross annual salary.

You can download the Referral Agreement and fax or mail the form directly to our office. A Midwest Nannies, Ltd. counselor will call you upon receipt of the Family Application. We look forward to working with you and guiding you through the nanny hiring process.

Click here for the Referral Agreement Form
PDF format, requires Adobe Reader

Contact Information
Date Nanny Needed:
Mother's Name:
Father's Name:
Home Telephone:
Home Fax #:
E-mail address:
Address:
City:
State:
ZIP Code:
Major Cross Streets:
Marital Status:
If divorced or separated, please describe the situation:
Name of parent NOT living with children:
Address of parent NOT living with children:
Phone number of parent NOT living with children:
Employment Information
FATHER
Father's Employer:
City:
State:
Phone:
Fax:
Work Hours:
Overnight Travel:	Yes No
On Call Situation:	Yes No
Do you work from a home office:	Yes No
If yes, please list days and hours:
MOTHER
Mother's Employer:
City:
State:
Phone:
Fax:
Work Hours:
Overnight Travel:	Yes No
On Call Situation:	Yes No
Do you work from a home office:	Yes No
If yes, please list days and hours:
Please note any "special need requirements," such as week-end work or rotating schedules:
Children
First Child's Name:
Gender:	M F
Date of Birth:
Grade in school:
Special Needs, Gifts, or Interests:
Any medical or health problems? If yes, please explain:
Second Child's Name:
Gender:	M F
Date of Birth:
Grade in school:
Special Needs, Gifts, or Interests:
Any medical or health problems? If yes, please explain:
Third Child's Name:
Gender:	M F
Date of Birth:
Grade in school:
Special Needs, Gifts, or Interests:
Any medical or health problems? If yes, please explain:
If you have more than three children, please enter the additional information here:
Briefly describe the goals/values you instill in your child(ren) and value in your nanny:
Family Information
Briefly describe your family lifestyle:
Family hobbies, interests, etc.
Briefly describe your approach to child rearing:
Briefly describe your discipline philosophy:
Do you have a cleaning service:	Yes No
Do you employ any other household staff:	Yes No
Pets
What kind:
How many:
If dogs, what breed:
Current Childcare
What is your current form of childcare:
How long have you had this arrangement:
If you have a nanny, why is she leaving:
May we contact her:	Yes No
Current Nanny's name:
Current Nanny's phone:
Nanny/Household Information
Nanny Position Needed, please check all that apply:	Live-In Live-Out Full-Time Part-Time
Nanny's work schedule (please indicate days and hours:	Monday Tuesday Wednesday Thursday Friday Saturday
If flexible, please explain:
What is the salary range you expect to pay?
Will you withhold taxes?	Yes No
Special benefits (i.e. Vacation, Health Insurance, Car, Holidays, Overtime)
Does Nanny need her own car?	Yes No
How much transportation is required?
Live-In Information
Will Nanny have her own bedroom?	Yes No
Will Nanny have her own bath?	Yes No
Will Nanny have her own TV?	Yes No
Will Nanny have her own Phone Line?	Yes No
Other Live-in Information:
Any special skills required?
Will you pay for courses?	Yes No
Is there a swimming pool or waterway on the property?	Yes No
If yes, where is it located?
What household responsibilities are required of the nanny?
What qualities are most important to you in selecting your nanny?
Please list any physical traits and/or other characteristics you are looking for:
Job Responsibilities
Please check all that apply:	Make Child(ren)'s bed Child(ren)'s laundry Child(ren)'s meals Clean child(ren)'s toys Light Housekeeping Shopping for child(ren) Transport child(ren) Car pool
Other Housekeeping Duties
This list is not part of a nanny's regular duties and should be negotiated between the family and the nanny.
Please check all that apply:	Family Laundry Make family's beds Family meal preparation Vacuuming and dusting Grocery Shop Run errands Pet care Travel with family Plant care Other (specify below)

Additional Information
Please list names and phone numbers of two personal references who have known you for two years or more:
When and where can you best be reached?
Do we have your permission to give your phone number to a possible nanny candidate if we need to quicken the search process?	Yes No
Which phone number:
Are you registered with any other agency?	Yes No
If yes, which agency or agencies?
Referred by:
"I certify that the facts contained in this Family Application are true and complete to the best of my knowledge and understand that falsification of this Application in any detail is grounds for disqualification from further consideration for placement of a nanny. I further agree that any false or misrepresentation made on this Application will invalidate any right to a refund and/or replacement under the Midwest Nannies, Ltd. Referral Agreement. I authorize investigation of all statements contained herein and authorize you to contact all the references listed above, and others, to give you any and all information concerning employment and any pertinent information they may have; and release all parties from all liability for any damage that may result from furnishing same to you."
I agree	I disagree

phone (815) 344-5899
temporary service (630) 248-7777
fax (815) 344-5868

“I called five nanny services listed in the yellow pages and Midwest Nannies Ltd. was the only one who even returned my call. Not only did they return my call, they followed through and found me a nanny. Very professional yet friendly!”
C.B. Oswego, IL

phone
(815) 344-5899

temporary service
(630) 248-7777

fax
(815) 344-5868

Serving the Chicago area, and north, northwest, west and south suburbs of Illinois

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