Family name:

First name:

Address:

Home phone:

Work phone

Mobile phone:

Fax:

Email:

Mums occupation:

Business name:

Business address:

Phone: Direct line:

Fax: Email:

Work: Please select one Full-time Part-time

Dads occupation:

Business name:

Business address:

Phone: Direct line:

Fax: Email:

Work: Please select one Full-time Part-time

Name:

Age: DOB: Sex: Male Female

Name:

Age: DOB: Sex: Male Female

Name:

Age: DOB: Sex: Male Female

Name:

Age: DOB: Sex: Male Female

Name:

Age: DOB: Sex: Male Female

Do the children have any medical conditions/disabilities or special requirements?

Yes (if yes, please state below)

Do the children have any allergies?

Yes (if yes, please state below)

Any dietary restrictions?

Yes (if yes, please state below)

Do the children take any medication?

Yes (if yes, please state below)

Will the carer be required to administer this medication?

Yes (if yes, please state below)

(If yes please provide the carer with written instructions on
what, when, & how much of this medication is required)

Do the children have any special interest/activities that they enjoy or attend?

Yes (if yes, please state below)

Will the carer be required to accompany them to these activities?

Yes (if yes, please state below)

Starting date:

Position status: (check as many as appropriate)
Live-in Live-out Mothers helper
Nanny Before / After school carer
Mummy nanny
Granny nanny

Please state hours and days required:
Day / Hours

Rate of pay:

Rate for extra work or overtime?

Other benefits

Payed sick leave. please state days per year

Payed annual leave please state days per year

Will the carer be required to take leave at particular times of the year?
(If yes please give details)

How much responsibility will the carer have of the children?
Please select 50 / 50 Sole charge Parent work from home, carer takes full charge Parent available sometimes Other

If Other please give details:

Are you accessible by public transport? Select one Yes No

Is a drivers licence required for the position? Select one Yes No

Will a vehicle be supplied? Select one Yes No

If yes is it auto or manual? Select one Auto Manual

Are you insured for driver under 25 years of age? Select one Yes No

Will the carer be required to use his/her own vehicle during employment? Select one Yes No
(If yes. You will be required to reimburse the carer for any incurred cost associated
with the use of their vehicle during employment)

Will the carer be required to travel with the family? Select one Yes No

If yes will it involve Select one Domestic International

How often do you require the carer to travel with the family?

Do you intend to use Care for Kidz as your exclusive agency? Select one Yes No
(If yes you will receive 1 years free membership to the mothers club,
free job advertising on our web page & newspapers.)

Is this a formal household? Select one Yes No

How do you expect the carer to address the family? Select one Family name First name Child's full name Nickname

Do you expect the carer to answer the phone? Select one Yes No

If yes how would you like the phone answered?

Will the carer receive a set of keys to the family home? Select one Yes No

Will the carer need to be familiar with security systems/procedures? Select one Yes No
(If yes please provide the carer with these details in writing)

Please state which areas of the home that is off limits to the children?

Please state which areas of the home that is off limits to the carer?


Is your home child proof? Select one Yes No

Do you require the carer to speak a second language? Select one Yes No
If yes please state

Will lunch or dinner be provided during working hours? Select one Yes No

Will the carer be required to eat their meal with the children/family during working hours? Select one Yes No

The family will provide food consumed by the carer? Select one Yes No Restrictions
If Restrictions please detail here

Will the family provide any extra items requested by the carer
for the amount up to $ per week? Select one Agree Disagree

Any items that the carer cannot consume or bring into the family home? Select one Yes No
If Yes please detail here

Will the carer have his/her own phone line? (Live-in only) Select one Yes No

Will the carer have access to the phone? Select one Yes No

The family will only cover local calls. Agree Select one Yes No

Any STD, mobile, International & competition lines will be
covered by the carer. Agree Select one Yes No

Any other benefits not covered that you would like to provide the carer with?
(eg mobile phone, private use of car, Internet access etc) Select one Yes No
If Yes please detail here

Please state facilities available:
Select all applicable Self-contained Own room Own bathroom Shared bathroom Own TV / Video Double bed Single Bed Other If Other please detail here

Do you require the carer to leave the home on days off? Select one Yes No

Would you mind if the carer leaves on days off? Select one Yes No

Do you expect the carer to “disappear” when the children are asleep?
Select one Yes No

Food will be provided on days off. Agree Select one Yes No

If yes will the carer eat with the family? Select one Yes No

If no the carer must have access to kitchen facilities. Please provide details of when these facilities can be available:

What are the television & music rules of the household?

Is the carer allowed to have visitors over? Select one Yes No Restrictions
Restrictions please provide details:

Restrictions please provide details:

Is the carer allowed to use facilities on days off? (eg tennis court, pool…)
Select one Yes No Restrictions
Restrictions please provide details:

Any other information, benefits, household rules not covered in this application please provide details
(eg time limits on phone/internet usage, housekeeping in own room, use of washing facilities…)

Carers are only required to do housekeeping duties for the children and the children only
ie: tidying, cleaning any work areas, washing, ironing, vacuuming and mopping any work areas,
cleaning children’s bathroom, taking children to appointments, activities and any other duties
that may be required for the children. Housekeeping duties for the family will not be preformed.
(For Mothers helpers Housekeeping duties will be shared 50/50)

Describe the type of person you will require and the personality that best suits your family life
(eg quiet, organized, talkative, outgoing etc)


Please describe any skills or abilities you require?



What are your thoughts on bringing up children?


Any additional information you would like to add. Please state?

Before submitting, please be sure that all information you can enter is correct.
If any necessary fields are left blank a Care for Kidz representative will be in touch
as soon as possible to clarify.