Sitter Solutions -  Nanny Application Please note most fields are Required on the application.  After you submit your application you will be contacted for an interview time Your name: Address: Cell: Phone: e-mail: Emergency  Contact: (name & relationship) Emergency  Contact Phone number: Please list all addresses for the last 5 years: Social Security Number: Date of Birth (optional): Driver's License Number: Exp. Date Yes No Have you ever been licensed in another State? Yes No Any tickets, arrest, charges, or convictions If yes, please explain: No Yes US Citizen? Have you ever been accused or substantiated as a perpetrator of child abuse or neglect investigated by a child-related social services agency? Yes No If yes, please explain: EDUCATION: College: Name: City & State GPA Year of Graduation Degree High School: Name: City & State GPA Year of Graduation Degree Other: (GED, Vo-tec, etc. Name: City & State GPA Year of Graduation Degree Please list any extracurricular activities while in High School and/or College: EXP Date CPR Yes First Aid? No Yes No EXP Date List any Child Development, Elementary or Special Education Classes: Yes Any experience with special needs in children? No Employment History: Employer 1: Add & Phone Hourly Rate Position Dates (to/from) Reason for Leaving: Employer 2: Add & Phone Hourly Rate Position Dates (to/from) Reason for Leaving: Employer 3: Add & Phone Hourly Rate Position Dates (to/from) Reason for Leaving: References: Name & Relationship Add & Phone Name & Relationship Add & Phone Name & Relationship Add & Phone *** Please have at least 2 written letters of recommendation.  You can bring them to the interview or have them e-mailed. Do you have your own Car? Full coverage Insurance? Yes No Yes No How far are you willing to drive one way to work? Yes No Liability only - Insurance? Disclaimer: We reserve the right to reject any candidate. To the best of my knowledge, all information on this application is true.  I understand that any false or misleading information or omission of pertinent information will result in the rejection of my application., or in dismissal if discovered subsequent to my association with Your Sitter Solution, LLC. Yes No I agree to the above Disclaimer Disclosure: This document serves solely as a clear and conspicuous written disclosure as required by the Federal Fair Credit Reporting Act set forth in section 604(b) to the Candidate that previous employment, education, social security, credit, motor vehicle report, and criminal background checks may be obtained for the purpose of this “Application” only.  By signing below, the applicant acknowledges this disclosure. Yes No I agree to the above Disclosure: Authorization: I authorize Your Sitter Solution, LLC to request reference checks, which include information on character and skills, education, driving and police records, past and present employment, addresses, social security number, and credit history. I permit Your Sitter Solution, LLC, to show this information to parents (if requested) as part of the evaluation process. I understand that all information in this application is requested in order to evaluate my qualifications for employment by parents as a child sitter.  I understand that I am not an employee of Your Sitter Solution, LLC, but shall be the employee of each individual family that hires me, responsible for paying any and all applicable taxes on any earnings. Your Sitter Solution, LLC is not responsible for any actions, circumstances or events that occur involving the applicant while performing any part of an agreement with Your Sitter Solution, LLC, including for negligence.  Applicant shall indemnify and hold harmless Your Sitter Solution, LLC, for any costs incurred in defending or paying for acts or omissions committed by the applicant, including reasonable attorney’s fees.   I understand that Your Sitter Solution, LLC, is not responsible for any act initiated by myself and I agree not to hold Your Sitter Solution, LLC, responsible for any and all claims including attorney fees and court costs made by any person arising out of my association. I agree to the above Authorization: No Yes Nanny Job Duties & Discription Please check all that apply or fill in where indicated Part time (live out) nanny: Temporary Nanny: Full time (live out) nanny: Full time (live in) nanny: Available to start? Been involved in a Worker's Comp Claim: Willing to work while parent is at home: Yes, I have been fired from a job before: Have lived alone: Have traveled alone: Do you smoke: How many hours do you need? Please disclose if you have ever had a DUI or other alcohol related offense, been treated for drug or alcohol use, been treated for depression, or can not go more than 8 hours without smoking:                                                    Children only                  Family included             not willing to do           Cooking Cleaning Laundry Errands Activities Grocery Shop Travel or extended stay Do you have children? If so, what are your daycare/sitting arrangements? How far would you be willing to drive for work? Do you have experience driving on snowy or icy conditions? What ages do you feel most comfortable with? How many children do you want to care for at one time? Short Answer Questions: 1.  Why do you want to be employed as a nanny/sitter? 2.  Please summarize your experience with children.  Include your position, ages, numbers of children and the scope of your responsibilities. 3.  Please describe your family and your family background. What was it like when you were growing up? 4.  Please define your value system? (What is most important to you?) 5.  What do you consider your personality strength and weakness? 6.  What type of parenting style would you most likely use within your own family? 7.  What do you expect from the family you work for? 8.  Please describe your lifestyle and your interest. 9.  What is your experience with household management? 10.  Why are you looking for a new position? 11.  What did you like most and least about your most recent childcare position? 12.  What is a sample lunch for a 4 year old? 13.  What activities would you plan on a typical 8 hour day for a preschooler? 14.  Please describe how you would handle the following situation:  Bobby was struck by a baseball and is unconscious? Health Information Do you Smoke?  If yes, how much and how long can you go before you need a cigarette? How often do you drink Alcohol? Do you use recreational drugs? Are you presently covered by health insurance? Have you ever been treated for the following medical conditions:  Asthma, Heart disease, Epilepsy, Nervous Conditions, Depression, Diabetes, HIV/AIDS, Meningitis, Eating Disorders, Hepatitis?  If so, please explain situation and course of treatment. Have you had or been vaccinated for chicken pox? List any medications that you are currently taking? List any allergies (medicines and/or environmental): List any physical impairments or conditions that need to be disclosed to the family? Do you like animals and will you be willing to work in homes with indoor pets? All information that is listed in the Health information section of this application is true and accurate.   Name: Date: CHILD DEVELOPMENT TEST 1.  All of the following are acceptable sleeping positions for a newborn except: a.  Lying on Right Side b.  Lying on Left Side c.  On Back d.  On Tummy e.  45 degrees upright in a bouncy seat, car seat, or swing 2.  Which of the following should not be given in the first year of life?  (List all that apply) a.  Honey b.  Egg yolks c.  Egg whites d.  Peanut butter 3.  Which of the following are acceptable measures to console a colicky baby?   (List all that apply) a.  allow them to cry it out b.  put baby in carseat and place on top of dryer and start dryer c.  drive child around in a car d.  place in baby swing e.  feed the baby f.  turn on vacuum cleaner g.  turn radio to static h.  turn on running water i.  rub the belly in a circular pattern j.  call parents home True/False:  (please check first box for True; Second box for False) 1.  Crying or colic begins at 2-3 weeks, peaks at 6 weeks then subsides by 16 weeks. 2.  Playing classical music in infancy stimulates brain development. 3.  Leaving a bottle in an infant’s mouth while sleeping can cause baby bottle tooth decay. 4.  Feeding an infant in a flat, lying position increases the risk of ear infections. 5.  It is acceptable to prop an infant’s bottle in order to free your hands for other activities. 6.  Babies up to 12 weeks can only breathe thru their noses and not their mouths. 7.  Microwaving formula can cause “hot spots” in the formula and can cause burns to the throat. 8.  It is okay to microwave breast milk bottles. 9.  Baby walkers (not exersaucers) are safe toys. 10.  Foods common for causing choking in young children include peanuts, Popcorn, carrot sticks, whole grapes, raisins, hard candy. 11.  Games appropriate for a 1 year old include model talking, singing songs, pat a cake, peek a boo. 12.  A 9-12 month old should be placed in time out when doing something he or she shouldn’t be doing. 13.  Vitamin D (whole milk) should be given between 1 and 2 years to enhance brain development. 14.  One minute for every year of age is an appropriate time out  guideline. 15.  Infants and Toddlers are often picky eaters and should be given frequent meal and snack times with healthy choices. 16.  Kids are rarely developmentally ready to be potty trained before the age of 2. 17.  Sharing toys is a behavior that should not be expected until the ages of 3-4 when cooperative play is common, not parallel play. 18.  TV viewing under 2 years of age is not recommended by the American Academy of Pediatrics. 19.  Chores can be assigned as young as 4 years. 20.  Children as young as 6 should be given privacy and personal space. 21.  Kids ages 4-5 should be educated about stranger safety. 22.  Eating disorders are common in early adolescence (11-13 years). Sources: American Academy of Pediatrics, Caring for Your Child:  Birth to Age 5 American Academy of Pediatrics, Caring for Your Child:  Ages 5- 12 Parents as Teachers, Family Education Materials, 2001. Home