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A Choice Nanny: Arlington
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Parent Information Form

Parents, please complete the following form.

* Required Information
Contact Information
Father's First Name:
Father's Last Name:
Mother's First Name:
Mother's Last Name:
Street:	*

City:	*
State:	*
Zip Code:	*
General Location:
Home Phone:	*
Cell Phone:	*
E-Mail:	*
Best Time to Call:
How did you learn about our services:
Work Information
Father's Profession:
Company:
Location:
Phone:
Fax:
Mother's Profession:
Company:
Location:
Phone:
Fax:
Child Care Information
Select "All" Child Care Needs
Full Time M-F Live-In Part Time Ongoing Overnight Occas. Eves. Temporary Share-A-Nanny Vacation/Summer Tutor Care
Specific days and hours of care:

Start Date:
Start End:
Salary Range:
Please list special needs:
Please list health problems / allergies:
Please list medications:
May Nanny Smoke?
Need Meals Prepared?
Need Housework?
Do You Have Pets?
Need Infant Experience?
Need A Driver?
Need Handicapped Care?
Schedule Flexible?
Nanny Allowed to Bring Her Child?
Need a Swimmer?
Need Elderly care?
Children Who Require Care
Child #1
Child Name:
Date of Birth:	Format: mm/dd/yyyy
Male/Female:
Child #2
Child Name:
Date of Birth:	Format: mm/dd/yyyy
Male/Female:
Child #3
Child Name:
Date of Birth:	Format: mm/dd/yyyy
Male/Female:
Child #4
Child Name:
Date of Birth:	Format: mm/dd/yyyy
Male/Female:
Other Information
Best time for nannies to call you:
List other agencies with which you are working:
Will you be advertising on your own? If yes, where?
Describe your ideal nanny:

What type of child care have you had in the past?

Why was the care terminated?

List other family members living at home?

What type of accommodations can you offer a live-in?

Describe your household pets (are they friendly)?

Describe your housekeeping standards?

If your family has experienced any episodes of domestic violence, please explain:

If any of your immediate family members have ever been convicted of a felony, please explain:

Are there smokers in your home?
Do you have firearms in your home?
Are your firearms loaded?
Do children or nannies have access to your firearms?
References
Reference #1
Name:
Street:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Relationship:
Reference #2
Name:
Street:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Relationship:
Emergency Contact Information
Name:
Relationship to you:
Phone:
Client Acknowledgement and Release
I have read the acknowledgement and release and fully understand it and agree to its terms and conditions. *



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