The Washburn Agency Full Service Nanny and Domestic Placement Agency Serving the Greater Boston, MA Area

Registration Form

Client Information:
Name: *
Occupation:
Employed By:
Cell Phone: *
E-mail Address: *
Spouse Name (if applicable):
Spouse Occupation:
Spouse Employed By:
Spouse Cell Phone:
Spouse E-mail Address:
Home Address:
City:
State:
Zip:
Home Phone:
Fax:
Interested In:
Nanny Housekeeper Elder Care/Companion Household Manager Chef/Cook Personal Assistant
Other:
If you checked Nanny:
Number of Children:
Child #1 Name:	Child #2 Name:	Child #3 Name:
Child #1 Age:	Child #2 Age:	Child #3 Age:
Child #1 Sex: Male Female	Child #2 Sex: Male Female	Child #3 Sex: Male Female
Child #1 Medical/Special Needs:	Child #2 Medical/Special Needs:	Child #3 Medical/Special Needs:

If you checked Elder Care/Companion:

Age:
Sex:
Medical Needs:
Schedule/Position:
Full Time Part Time Live In Live Out
If live in: Please describe the living situation: (ie: private bedroom, private bath, separate/shared entrance.)

Please describe the expected schedule including start and end times:

Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
Is there any flexibility in hours?
Job Duties: (Check all that apply)
Nanny:
Childcare Only Childcare/Light Housekeeping Clean Up Kitchen Empty Dishwasher Keep Children's Room's Clean Make Beds Cooking (Please complete the cooking section) Driving Children
Please describe your home: (ie: square feet, number of bedrooms/bathrooms)
Housekeeping:
Clean Kitchen Make Beds Dust Vacuum Clean Bathrooms Wash Floors Wash Dishes Wash Clothes Wash Linens Iron Clothes Iron Linens
Cooking:
Children's Meal's Only Gourmet Cooking Plain Cooking Family Cooking Family Serving Menu Planning Formal Serving
Any dietary or religious restrictions?
Household Management:
Supervise Staff Hire Staff Run Errands
Computer Skills?
Other duties required?
Other Criteria:
Non-smoker?
Yes No
CPR Certified?
Yes No
First Aid Certified?
Yes No
Driver?
Yes No
Must own their own car?
Yes No
Do you have pets? Please describe:
Is there any pet care?
Yes No
Any travel? Please describe: (ie: how often, required schedule, accommodations.)
Are there any languages spoken in your household besides English?
Is your home accessible via public transportation? If so, please describe:
Anticipated Start Date:
Compensation/Benefits:
Approximate salary range (please be specific).
Is a car provided?
Yes No
Is the car available for use while the individual is off duty?
Yes No
Holidays: Off and Paid?
Vacation: Number of weeks paid?
Other benefits offered: (ie: Health Insurance, Bonuses, Travel, Tuition Reimbursement, etc.)
Additional Comments?
How did you hear about The Washburn Agency?


* Required

Client Information:

Interested In:

If you checked Nanny:

If you checked Elder Care/Companion:

Schedule/Position:

Please describe the expected schedule including start and end times:

Job Duties:

Nanny:

Housekeeping:

Cooking:

Household Management:

Other Criteria:

Compensation/Benefits: