1. family and parenting
2. children

Bay Area 2nd MOM, Inc.
Nanny/Senior Care, Long Term, Temporary and On-Call Referral Service
Dear Nanny Candidate,
Thank you for contacting Bay Area 2nd Mom Nanny Referral agency for employment. We are
looking forward to working with you to find the best position that suits your interests and
matches your experience level.
To help you improve your skill level and to meet specific requirements, we have contracted with
a local non-profit agency to provide Safety and Child Care Training. Classes are held many
times in the month on days convenient to most schedules. Call us and use option #4 to
schedule your CPR, First Aid or Basic Nanny Training course. Safety classes follow the
American Heart Association policies and meet with the standards of the State of California
Emergency Medical Services Authority.
For you convenience an application is attached for you to review and complete. It is best to
schedule and interview to allow us to meet with you in person to review your application and
discuss your work objectives. Call us at your earliest convenience once you’ve completed your
application for an interview.
PLEASE BRING AS MANY OF THE FOLLOWING ITEMS WITH TO THR INTERVIEW:
1)
2)
3)
4)
5)
6)
7)
References: (Include-Employer names, telephone numbers and addresses of the places where you
worked)
Identification (at least drivers license and social security and one other)
a) Driver’s License or State Issued ID
b) Social Security Card
c) Birth Certificate
d) Passport
e) Green Card
Work Authorization or Permanent Residency Card (If not a US Citizen)
CPR and First Aid cards (Course must cover skills for all ages and be current).
Proof of TB Test or Chest X-ray (Less than one year since test)
DMV driving record Printout
(Must be original dated less than 3 months since printing)
Letters of recommendation from employers and personal acquaintances (Optional)
If you are unable to obtain any or all of these documents it is your responsibility to discuss the
circumstances with your counselor. Your originals will be copied and returned to you during
your interview. We can help you to obtain documents such as driving records and social
security card.
Thanks you for contacting Bay Area 2 nd MOM to assist you with your next child care position.
Best regards,
Bay Area 2nd Mom, Inc.
www.2ndmom.com
q Palo Alto Office - 872 San Antonio Rd, Palo Alto CA. 94303 Tel: 650-858-2469, Fax: 650-493-6598
q Emeryville Office - 6400 Hollis Street Suite 8, Emeryville, CA. 94608 Tel: 888-926-3666, Fax: 510-595-1350
Bay Area 2nd MOM, Inc.
Nanny Application
Date of Application:
Personal Information (Please complete in black ink)
Name
Social Security #
Home Address
Home phone
Fax Number
-
-
Date of Birth
City
(
)
† Call First
Cell phone
(
)
(
/
Zip
State
)
Work Phone
/
(
)
Email Address
What is the best way to reach you during the day (home phone/cell phone/email)?
Marital Status: check one (Optional)
Do you have children?
† Single
† Married
† Yes † No
† Separated
† Divorced
† Widowed
† Other
Do you need to bring your children to work with you?
† Yes † No
Please tell us about them (Name, age, DOB)
Friend or Relative to contact in case of emergency
Name
Relationship
Phone (H)
(
)
Other
(
)
Name
Relationship
Phone (H)
(
)
Other
(
)
Please Check Yes or No and fill in the appropriate information:
Do you have a driver’s license?
† Yes † No
Make/
Model
Issuing State
Do you have car insurance?
† Yes † No
Name of Insurer
Are you a U.S Citizen?
† Yes † No
Can you legally accept employment?
† Yes † No
Are you a Permanent Resident?
† Yes † No
Card Number
Exp Date
/
/
Do you have Work Authorization?
† Yes † No
Card Number
Exp Date
/
/
Do you have a car?
† Yes † No
Have you ever been convicted of a felony or misdemeanor?
Number
Color
Exp Date
Year
State
/
LP#
Policy Number
If no, a citizen of what country?
† Yes † No
If yes, please explain:
How did you hear about Bay Area 2nd MOM, Inc?
(Please be specific)
Are you looking for a position on your own?
† Yes † No
Are you working with other agencies?
† Yes † No
Property of Bay Area 2nd MOM, Inc.
Who?
1
/
What kind of position are you interested in? (Check all that apply)
† Long-Term (over 12 weeks)
† Temporary/Summer (1 – 12 weeks)
† Live-in
† Live-out
† Full-time (over 25 hours/wk)
† Part-time (under 25 hours/wk)
† On-Call (as-needed)
If temporary, what periods of time will you be available?
What hours are you available to work?
From
To
Total # of
Hours
† Monday
____________
____________
____________
† Tuesday
____________
____________
____________
† Wednesday
____________
____________
____________
† Thursday
____________
____________
____________
† Friday
____________
____________
____________
† Saturday
____________
____________
____________
† Sunday
____________
____________
____________
Day
Are you willing to do a split shift? (Example 7:00 am – 8:30 am and again from 2:00 pm to 7:00pm)
Date available to start:
/
/
Expected Salary Range
Please check all age ranges that you have experience in:
† Yes † No
$
Please check any special needs that you have experience with:
† Infant Care (NB – 6 mo)
† ADD
† Hearing Impaired
† 6 mo – 2 yrs
† ADHD
† Physically Handicapped
† 2 yrs – 7 yrs
† Autism
† Mentally Handicapped
† 8 yrs and over
† Asthma
† Emotionally Disturbed
† Blind
† Down’s Syndrome
† Cerebral Palsy
† Multiple Disabilities
† Medical Illness
† Diabetes
† Elderly
(Age)
† Multi-birth experience
† Twins Age)
† Triplets (Age)
† Two children of the same/similar age
(Ages)
† Other
Please check all of the following that you are willing to do:
† Run errands
† Tutor children
† Swim with children
† Care for Pets:
† Cat:
___ Indoor
___ Outdoor
† Bird
† Reptiles
† Farm Animals
† Dog:
___ Indoor
___ Outdoor
† Fish
† Insects
† Rodents
† Housekeeping:
† Light
† Heavy
† Laundry:
† Children
† Family
† Cooking:
† Children
† Family
† Drive Children:
† Your Car
† Family Car
† Manual
† Automatic
† Travel:
† Domestic
† International
† Weekend
† Extended
† Work in a home where there are guns
Property of Bay Area 2nd MOM, Inc.
Comments:
2
Print Name
HEALTH INFORMATION
Do you have medical insurance?
† Yes † No
Insurance Carrier
Physician’s Name
Office Address
City
Please check a Yes or No box and provide more detail if necessary
1.
Have you had a physical within the last 5 years?
2.
Have you had the chicken pox?
3.
4.
Do you have any allergies to animals or foods?
Do you have any physical, medical or mental disability, which
would prevent you from performing specific work?
5.
Do you have any physical limitations?
6.
Do you take prescribed medications?
7.
Do you smoke? If YES, specify amount & how often.
8.
Do you drink alcohol? If YES, specify amount & how often.
9.
Are you currently being treated for a drug or alcohol problem?
Do you now or have you ever been treated for any back
disorder/injury?
10.
11.
12.
Are you now receiving Workmen’s Compensation?
Have you changed or been advised to change occupation or
residence for health reasons?
13.
Do you have any special medical considerations?
14.
Have you had any major operations/illnesses?
YES
State
NO
Zip
IF YES, PLEASE EXPLAIN
Do you have or have you ever been diagnosed with:
Arthritis
Diabetes
Hernia
Emotional Problems
Epilepsy or Convulsions
Fainting or Dizziness
Frequent Headaches
Cancer
High Blood Pressure
Heart Disease
Chest Pain or Pressure
Chronic Coughs, colds, or sore throats
Allergies, Asthma, Wheezing
Skin Disease
Signature
Property of Bay Area
Date
2nd
MOM, Inc.
3
Print Name
Please describe your education
Name of Institution Attended
give City and Sate or Country
Dates Attended
From
To
Degree Earned/Certificate Received
High School
Community College
College or University
Graduate/Professional School
Other courses/certificates earned
What languages do you speak and how fluent?
What are your hobbies/special interests?
Describe your family background.
Why are you interested in this type of work?
What are your selling points? (What makes YOU best suited for this job?)
What activities would you like to share with children?
What form of discipline do you believe is most effective?
What are your long-term career/job goals?
Property of Bay Area 2nd MOM, Inc.
4
Print Name
CHILD CARE RELATED REFERENCES
(Outside of your friends and/or family)
Please list your most recent references first and contact your references to let them know that they will be contacted.
Employer
Date
Started
Contact Name
May we contact? † Yes † No
Still employed? † Yes † No
† Reference Letter?
Home phone
(
)
Cell phone
Work phone
(
)
Email Address
Home Address
(
)
City
Position Title
Avg. hrs. per/ wk.
Was the position:
___________________
Number of children
Date
Ended
State
† Full-Time
† Live-In
† Part-Time
† Live-Out
Zip
† On-Call, how often?
† Temporary
Name, gender, and age at time of hire
Job Duties
Reason for leaving?
Date
Started
Contact Name
Employer
May we contact? † Yes † No
Still employed? † Yes † No
† Reference Letter?
Home phone
(
)
Cell phone
Work phone
(
)
Email Address
Home Address
(
)
City
Position Title
Avg. hrs. per/ wk.
Was the position:
___________________
Number of children
Date
Ended
State
† Full-Time
† Live-In
† Part-Time
† Live-Out
Zip
† On-Call, how often?
† Temporary
Name, gender, and age at time of hire
Job Duties
Reason for leaving?
Employer
Date
Started
Contact Name
May we contact? † Yes † No
Still employed? † Yes † No
† Reference Letter?
Home phone
(
)
Cell phone
Work phone
(
)
Email Address
Home Address
Position Title
Avg. hrs. per/ wk.
(
)
City
Was the position:
___________________
Number of children
Date
Ended
† Full-Time
† Live-In
State
† Part-Time
† Live-Out
Zip
† On-Call, how often?
† Temporary
Name, gender, and age at time of hire
Job Duties
Reason for leaving?
Property of Bay Area 2nd MOM, Inc.
5
Print Name
CHILD CARE RELATED REFERENCES CONTINUED
Date
Started
Contact Name
Employer
May we contact? † Yes † No
Still employed? † Yes † No
† Reference Letter?
Home phone
(
)
Cell phone
Work phone
(
)
Email Address
Home Address
(
)
City
Position Title
Avg. hrs. per/ wk.
Was the position:
___________________
Number of children
Date
Ended
State
† Full-Time
† Live-In
† Part-Time
† Live-Out
Zip
† On-Call, how often?
† Temporary
Name, gender, and age at time of hire
Job Duties
Reason for leaving?
Employer
Date
Started
Contact Name
May we contact? † Yes † No
Still employed? † Yes † No
† Reference Letter?
Home phone
(
)
Cell phone
Work phone
(
)
Email Address
Home Address
(
)
City
Position Title
Avg. hrs. per/ wk.
Was the position:
___________________
Number of children
Date
Ended
State
† Full-Time
† Live-In
† Part-Time
† Live-Out
Zip
† On-Call, how often?
† Temporary
Name, gender, and age at time of hire
Job Duties
Reason for leaving?
Employer
Date
Started
Contact Name
May we contact? † Yes † No
Still employed? † Yes † No
† Reference Letter?
Home phone
(
)
Cell phone
Work phone
(
)
Email Address
Home Address
Position Title
Avg. hrs. per/ wk.
(
)
City
Was the position:
___________________
Number of children
Date
Ended
† Full-Time
† Live-In
State
† Part-Time
† Live-Out
Zip
† On-Call, how often?
† Temporary
Name, gender, and age at time of hire
Job Duties
Reason for leaving?
Property of Bay Area 2nd MOM, Inc.
6
Print Name
OTHER SIGNIFICANT WORK HISTORY
Please use this page to fill in any gaps in your childcare employment.
May we contact?
† Yes † No
Still employed? † Yes † No
(
)
Cell phone
Work phone
(
)
Email Address
Address
Was the position:
)
State
† Full-Time
Job Duties
Zip
† Part-Time
Reason for leaving?
Employer
Date
Started
Contact Name
† Yes † No
Still employed? † Yes † No
(
)
Cell phone
Work phone
(
)
Email Address
Address
(
)
City
Position Title
Date
Ended
† Reference Letter?
Home phone
Was the position:
State
† Full-Time
Job Duties
Zip
† Part-Time
Reason for leaving?
Date
Started
Contact Name
Employer
May we contact?
(
City
Position Title
Date
Ended
† Reference Letter?
Home phone
May we contact?
Date
Started
Contact Name
Employer
† Yes † No
Still employed? † Yes † No
† Reference Letter?
Home phone
(
)
Cell phone
Work phone
(
)
Email Address
Address
(
)
City
Position Title
Was the position:
Job Duties
Date
Ended
† Full-Time
State
Zip
† Part-Time
Reason for leaving?
CHARACTER REFERENCES
Do not include work references or relatives
Name
Address, City, State
Phone Number
1.
2.
3.
Property of Bay Area 2nd MOM, Inc.
7