Quality Care

A Full Service Nanny Placement Agency

Family Profile
Full Name
Date
Address
City
State
Zip
Phone (Home)
Fax (Home)
Cell Phone (Wife)
Cell Phone (Husband)
Work Phone (Wife)
Work Phone (Husband)
E-Mail (Wife)
E-Mail (Husband)
Background with caregivers:
Situation
Number of Kids	Need Driver? Yes
Schedule (Full-time, Part-time, etc.)
Start Date
Days of week needed
Days of week off
Hours (Start and end time)
Nights: Weekend
Nights: Weekdays
Description Care Giver	Live-In Live-Out Temporary Permanent
	Housekeeper AuPair Babysitter Combination Nanny Household Mgr.
Ideal Caregiver (Please Describe)
Swim?	Yes No
Non-Smoker?	Yes No
Smokers In House?	Yes No
Type experience?
Driving Required?	Yes No
Pets In House?	Yes No
Family Description (Any details you want us to know)
Describe Family Style (Organized/Casual)
Vacation with Nanny?	Yes No
Care Giver Friends Welcome In House?	Yes No
Responsibilities	Child Care Housekeeping Light Housekeeping Housekeeping/Cleaning Services
Daily Chores
Weekly Chores
Clean & Tidy Rating: (1 - Very Casual, 10 - Meticulous)
Family
Nanny
Meal Preparation
Dietary Restrictions	Yes No
Please Describe:
Kid Food	Yes No
Family Meal Preparation	Yes No
Dinner Dishes	Yes No
Family Eating Profile (Do you eat together? Kid's eat early, etc)
Parents Schedule
*Mom:*
Work Schedule
	In Home Outside of Home
Travel Frequency
Type Work
Other
*Dad:*
Work Schedule
	In Home Outside of Home
Travel Frequency
Type Work
Other
Other important information