Personal details
Name 

Email   

Home Tel.

Home Fax

Work Tel.

Work Fax

Mobile Tel.

Address 

Mother's Occupation

Father's Occupation


Family details
Marital Status
Married Single Separated Divorced
Mother's Nationality

Father's Nationality

Family Religion

Family Residence
House Flat
Other, please state

No. of children

Ages and sex

Any children with special needs? Please state

Do you have any pets ?


Type of staff required
Nanny Maternity Nurse Housekeeper Night Nurse Special Needs Nurse Private PA Total Mothers Help
Permanent Temporary
Daily Live-in
If live in, please describe accommodation

Previous Experience
Essential Preferred Not Essential
Car driver
Essential Preferred Not Essential
Non-smoker
Essential Preferred Not Essential
Start Date 

Length Of Stay 

Net weekly salary offered


Childcare responsibilities
Hours of work/weekly 

Shared Care
Yes No
Sole Charge
Yes No
Both parents work
Yes No
Any Babysitting
Yes No
If Yes, how many evenings per week
1 2 3 4 5 6 7
Nursery duties only
Yes No
Any extra duties
Yes No
Please state


Additional information Please give below any additional information or benefits you may feel will be helpful in finding the most suitable staff for your family (for example accomodation, car, holidays, second residence).