American Nanny - Email Application Form for Child Care Services

American Nanny & Family Care Services

APPLICATION FOR CHILD CARE SERVICES

Date:    Telephone Numbers

Name: Home:

Street: Work:

City:     Fax:

State: Zip Code:                  (000-000-0000)

E-Mail Address:

Best Time to Call:

Start Date for Care:

Parent's Occupations:

Names & Ages of children Personality, special needs and/or concerns

Describe the characteristics of a provider who could best meet your needs.

Please choose the type of care you are interested in at this time.

Family Home Child Care

Hours: Days: Cost:

What towns would you like your Child Care?

Please continue for Nanny only:

Live IN Live OUT
Full time(30+) Part time

Check the duties you will be expecting Nanny to perform.

light house work transporting children grocery shopping

prepare meals children's laundry pet care

Nannies who desire to bring their own child with them must meet specific qualifying criterion.

Would you consider this type of caregiver? Yes No Possibly

Describe other duties:

JoAnn Bergeron PO Box 1382, Amherst, NH 03031-1382 (603)471-1415 Fax(603)471-1416 manager@AmericanNanny.com

Date:		Telephone Numbers
Name:		Home:
Street:		Work:
City:		Fax:
State: Zip Code:		(000-000-0000)

E-Mail Address:
Best Time to Call:
Start Date for Care:
Parent's Occupations: