| Your Name: * |
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| Spouse's Name: |
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| Number of Children (name, dob, age & school): |
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| Your Occupation/Employer: |
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| Spouse's Occupation/Employer: |
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| Email Address: * |
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| Phone Numbers: * |
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| Home Address: |
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| City: |
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| State: |
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| Zip Code: |
(5 digits) |
| If applicable: Directions to your home: |
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| If applicable: Hotel where you will be staying: |
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| What day/s & time/s do you anticipate needing a sitter/nanny? |
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| How soon do you need a sitter/nanny?: |
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| What do you anticipate the duties of the sitter/nanny to be for your children? Are there any specific skills you would like her to have (swimming, Spanish, etc.)?: |
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| Describe the personalities, habits, likes, dislikes & activities of your children. Do they have any health issues?: |
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| Current Arrangements: |
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| Have you ever had a sitter/nanny before? What was your experience?: |
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| Do you have any pets? If yes, please describe.: |
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| Please provide us with 2 emergency contact names and phone numbers (other than the parents).: |
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| How did you hear about us? Google, Yahoo, Friend (if so, who), Craigslist, NM Kids or other (please explain).: |
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