App, EQ, TD driving release 2022 First Name(Required) Date MM slash DD slash YYYY PERSONAL INFORMATION Do you have any physical, dietary, or emotional limitations, which might affect your ability to work unsupervised with children with or without a reasonable accommodation? Yes No If yes, please explain:How many times in the past year were you sick resulting in absence from work? If requested, could you supply a doctor’s note stating that your immunizations are current? Yes No Would you be willing to obtain current immunizations including but not limited to covid vaccine/flu shot? Yes No Do you smoke? Yes No If yes, please state amount and frequency:Do you currently take any medication that can at any time reduce or obscure cognitive ability or delay reaction time, including but not limited to over-the-counter medications? Yes No If yes, explain medication and dosage:ABOUT THE POSITION YOU ARE SEEKING What type of position are you looking for? Please mark all that apply. Nanny Family Assistant On-call Childcare Mother’s Helper Household Manager What type of work arrangement do you prefer? Full-time (more than 35 hrs/wk) Part-time (less than 35 hrs/wk) On-call Backup Childcare How long of a commitment are you willing to make to an employer? 3-5 years 1-2 years Under 1 year. Please specify: Are you willing and able to perform the following with or without a reasonable accommodation? Yes No Lift up to 50 pounds from the floor to a standing position. Yes No Hold or carry up to 50 pounds while in a seated position. Yes Sit or kneel on the floor for up to 30 minutes. Yes Stand up quickly from seated position. Yes Sprint for one minute without resting. Yes No Listen to a loud, repetitive noise (such as hysterical crying) for up to 1 hour. Yes No Restrain a child of up to 80 pounds if became a physically dangerous threat to self or others. Yes No Remain awake for 14 consecutive hours without sleeping. WHAT AGES DO YOU HAVE EXPERIENCE WITH? Infants (under 1 year) Please state total amount of years: Infants (under 1 year) Please state total amount of years: Toddlers (1 – 2 years old) Please state total amount of years: Preschool Age (3 – 4 years old) Please state total amount of years: School Age (5 – 12 years old) Please state total amount of years: Teens (13+) Please state total amount of years:Untitled Twins, triplets, or multiple infants in daycare setting Please state total amount of years:DO YOU HAVE EXPERIENCE CARING FOR CHILDREN WITH SPECIAL NEEDS? If so, please check all special needs with which you have experience. ADD/ADHD Down Syndrome Food Allergies Visually Impaired Autism Hearing Impairment Learning Disabilities Diabetes Asthma Cerebral Palsy Other (please explain): No experience with special needs No experience with special needs CHILDCARE EMPLOYMENT HISTORY – THREE (3) REQUIRED *If you have more than three childcare positions to list, please use same format as above and email them to placement@seattlenanny.com1. Employer First & Last Name: Employed From: Employed To: Ages of Children When Job Began:Reason for Leaving: What Responsibilities Did You Have In This Position? Childcare Children’s Laundry Family’s Laundry Managing Family Calendar Light Housekeeping Complete Housekeeping Homework Assistance Driving Children Grocery Shopping Organizing Activities Traveling with Family Cooking for Children Meal Preparation Running Errands Outings with the Children Pet Care Washing Dishes Cooking for Family Other: CHILDCARE EMPLOYMENT HISTORY (Continued) 2. Employer First & Last Name: Employed From: Employed To: Ages of Children When Job Began: Reason for Leaving: What Responsibilities Did You Have In This Position? Childcare Children’s Laundry Family’s Laundry Managing Family Calendar Light Housekeeping Complete Housekeeping Homework Assistance Driving Children Grocery Shopping Organizing Activities Traveling with Family Cooking for Children Meal Preparation Running Errands Outings with the Children Pet Care Washing Dishes Cooking for Family Other: CHILDCARE EMPLOYMENT HISTORY (Continued) 3. Employer First & Last Name: Employed From: Employed To: Ages of Children When Job Began: Reason for Leaving: What Responsibilities Did You Have In This Position? Childcare Children’s Laundry Family’s Laundry Managing Family Calendar Light Housekeeping Complete Housekeeping Homework Assistance Driving Children Grocery Shopping Organizing Activities Traveling with Family Cooking for Children Meal Preparation Running Errands Outings with the Children Pet Care Washing Dishes Cooking for Family Other: NON-CHILDCARE EMPLOYMENT HISTORY 1. Company Name: Employed From: Employed To: What Responsibilities Did You Have In This Position? 2. Company Name: Employed From: Employed To: What Responsibilities Did You Have In This Position? CRIMINAL BACKGROUND Have you ever been convicted of a criminal offense (felony or misdemeanor)? Yes No If Yes, explain: Are you authorized to work lawfully in the United States? Yes No Have you ever molested or abused a child? Yes No If hired by a client of Seattle Nanny Network, Inc., are you willing to submit to and pass a controlled substance test? Yes No STATEMENT OF UNDERSTANDING: I understand that if I am being represented by National Nanny Network/Seattle Nanny Network, Inc. I will be introduced to families during the process of seeking and possibly securing employment. I understand that it is not appropriate for me to communicate directly with anyone I meet as a result of a referral through NNN/SNN, Inc. without the express permission of NNN/SNN, Inc. I understand this includes but is not limited to Text message, Phone, Email, Requests for friendship through social networking sites, requests for employment through online sitter posting board sites, or any direct or indirect solicitation for employment which excludes the knowledge of NNN/SNN, Inc. Untitled I agree to alert NNN/SNN, Inc. immediately to any solicitation for employment or sitting services, by any family, friend or neighbor that I meet as a result of being represented by NNN/SNN, Inc. I understand that social networks, photos, and postings are public and permanent information and if deemed inappropriate may have a detrimental effect on a client’s willingness to interview and/or hire me, which is outside of and beyond the control of the agency. Untitled I understand that should I take a position with a client of the agency without authorization, I may personally be held liable for the fees associated with the placement. Untitled I understand and acknowledge that if I accept a job with a client of the agency, unless otherwise indicated, I am expected to commit to at least twelve months. I acknowledge the financial, emotional, and logistical cost to the children, their parents, and the agency should I choose to leave my employer prematurely for whatever reason. I agree that long term stability and my own consistent employment history are of paramount importance and therefore I am willing to submit to a third-party consultation prior to submitting resignation, if requested. Untitled I agree that upon resignation or untimely dismissal from a position that I am required to submit the “exit form interview” to the agency. Untitled Finally, I acknowledge the agency invests significant time and resources into my file – although there is no cost to me. Out of respect for the effort National Nanny/Seattle Nanny puts into my job search, I can offer exclusivity for the following length of time:Untitled (14) Fourteen days from activating your search Untitled (30) Thirty days from first activating your search Untitled I cannot offer exclusivity. I am seeking jobs outside the agency. Applicant SignatureDate MM slash DD slash YYYY Security: Workplace Surveillance in the role of unsupervised caregiver in a private home or corporate event location This form acknowledges that you understand and agree to Seattle Nanny Network, Inc.’s policies on workplace monitoring and surveillance. Seattle Nanny Network, Inc. and their clients may choose to engage in both visual and audio surveillance activities in the workplace, and this form provides your consent that you understand Seattle Nanny Network, Inc. and their clients may engage in such visual and audio surveillance and monitoring practices. There should be no expectation of privacy in the workplace except in private areas such as designated restrooms and dressing areas. Workplace surveillance not only protects Seattle Nanny Network, Inc. and their client’s children and property, but also extends protections to the nanny or caregiver in cases of false accusations, abuse, behavioral issues with the children, etc. Our goal is to ensure full transparency and maintain the highest level of professionalism for all parties involved. Applicant SignatureDate MM slash DD slash YYYY Please read first: THE FOLLOWING QUESTIONS ARE AN IMPORANT PART OF THIS APPLICATION! THE RESPONSES TO THESE QUESTIONS WILL BE SHARED WITH PROSPECTIVE EMPLOYERS AS THEIR INTRODUCTION TO YOU! Please write your answer under each question. 1.Describe your professional childcare experience and work history, including any gaps in employment history. If you have not been a nanny, explain why you would excel in this role.2.How would your former employers and friends describe you?3.In your work with children, what are your personal strengths?4.How do you define the nanny’s role in the family?5.Please describe in detail what sets you apart from any other candidate? (i.e. education, training and certifications (Documentation required), household management experience, teaching or tutoring experience, cooking skills, etc.EmailThis field is for validation purposes and should be left unchanged.