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

Application for Temporary Service

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 the application below we can begin the process of introducing you to nannies in our pool of candidates. We will need a signed Placement Agreement as well.

For a printable version of the Placement Agreement for a temporary Nanny, click here. PDF format, requires Adobe Reader

You can download this placement agreement and fax the form directly to our office or a Midwest Counselor will call you upon receipt of this application online. We look forward to working with you and guiding you through the hiring process.

Job Order - Temporary Clients
Contact Information
Client Name:
Spouse's Name:
Home Telephone:
Home Fax #:
Father's Work Phone:
Father's Work Fax:
Mother's Work Phone:
Mother's Work Fax:
E-mail address:
Address:
City:
State:
ZIP Code:
Major Cross Streets:
Care is for:
First Child's Name:
Date of Birth:
Special Needs (i.e. physical disability, behavioral concerns, medication, allergies, etc.)
Second Child's Name:
Date of Birth:
Special Needs (i.e. physical disability, behavioral concerns, medication, allergies, etc.)
Third Child's Name:
Date of Birth:
Special Needs (i.e. physical disability, behavioral concerns, medication, allergies, etc.)
If you have more than three children, please enter the additional information here:
Do you have any pets in/out of the home:	Yes No
Please describe your pets:
Job Description:
Dates Care Needed
To Be Determined	Yes No
Specific Dates: (please enter the dates and the "from and to" times needed on each date)
Ongoing Temporary Schedule: (please enter "from and to" times needed on each day)	Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Any special instructions:
Caregiver Profile
Please indicate by marking the following questions if you have a preference.
Allow nanny to bring own child?	Yes No
Non-Smoking household ?	Yes No
Non-Smoking caregiver?	Yes No
Need own car on job?	Yes No
Will supply car on job?	Yes No
Swimmer?	Yes No
Additional Caregiver Profile:
AGENCY POLICIES
A $30.00 First day agency fee is due upon receipt of paperwork for all childcare, new mother/baby care, andall overnight extended care jobs. This First day agency fee will be charged every year to continue service. The Agency charges a $15.00 per day agency fee for each day a caregiver is referred. A TemporaryPlacement Agreement will be enclosed and should be signed and returned to the office. Caregivers cannot leave their telephone number, but can be contacted through the Agency. All Placement Fees owed Midwest Nannies, Ltd. are due and payable prior to Nanny's first day ofemployment. The Placement Fee referenced in this Agreement will automatically be charged to Client's creditcard account The Client must provide to Midwest Nannies, Ltd. a valid credit card number, including expirationdate, as a guarantee of payment and Client hereby authorizes Midwest Nannies, Ltd. to place charges on saidAccount in accordance with this Agreement.
"I have read, understand and agree to the Agency Policies as stated above."
I agree	I disagree

phone (630) 513-9034
temporary service (630) 248-7777
fax (630) 513-9092

Serving the Chicago area, and northern Illinois including all of the Chicago suburbs

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“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
(630) 513-9034

temporary service
(630) 248-7777

fax
(630) 513-9092

Serving the Chicago area, and northern Illinois including all of the Chicago suburbs

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