AA Clara's Nanny Agency

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Caring for active Canadian families

Caregiver Application Form

If you are interested in working for a family in Canada, or would like more information, please complete this Caregiver Application Form.

The better we understand your experience and preferences, the quicker and easier we can find a family who will be a great fit. We will review your information and contact you by email or phone, usually in 1-2 business days.

Position Desired

What position(s) are you interested in?

Caring for children
Caring for the elderly
Caring for persons with disabilities
Housekeeping
Preparing meals

Would you prefer to live with the family in their home?

Yes ("live-in") No ("live-out")

Your Contract Information

Family name:

Given name(s):

Gender:

Male Female

Street address:

City:

Province or state:

Postal code:

Country:

Phone (include country code and city/area code):

Mobile phone (include country code and city/area code):

Fax (if available):

Email:

About You

Date of birth:

Place of birth (city, country):

Country of citizenship:

Skype name:

Knowledge of English

Very good Good Fair

Other languages spoken:

Religion:

Height:

Weight:

How is your general health?

Marital status:

Number of dependents:

Highest education/training (level/degree, discipline):

Mother's occupation:

Father's occupation:

Your Work Experience

What housework have you done in the past?

Doing laundry
Ironing
Cooking
Baking
Waiting at table

If you have brothers or sisters, what ages are they?

Do you have a driver's licence?

Yes No

If yes, for how long?

years

Have you taken care of children / the elderly / persons with disabilities?

Yes No

What ages?

Do you like pets?

Yes No

Do you have any allergies?

Do you smoke?

Yes No

If yes, how many cigarettes a day?

Do you swim?

Yes No

What outdoor sports, if any, do you like?

What are your hobbies and interests?

Do you prefer a household with few or many children?

Few (1-3) Many (4 or more)

Ages preferred:

Where would you prefer to work?

City Suburb Small town Rural area

Do you have relatives or friends living in Canada?

Yes (provide details below) No

Name:	Relationship:	City, province:	Phone:	May we call?
				Yes No
				Yes No
				Yes No

Your Present Employer

Present employer's name:	City, country:	Phone:	May we call?
			Yes No
Duties: From: To: Reason for leaving:

Previous employer's name:	City, country:	Phone:	May we call?
			Yes No
Duties: From: To: Reason for leaving:

Previous employer's name:	City, country:	Phone:	May we call?
			Yes No
Duties: From: To: Reason for leaving:

Other Important Details

Do you have a valid passport?

Yes No

Are you able and willing to sign a one-year contract?

Yes No

When are you available to start work?

Have you applied previously for a work permit for Canada?

Yes No

Was your application for a work permit ever refused?

Yes No

If yes, for what reason?

Please feel free to elaborate on any of the above if you wish, or describe any other relevant experience you have.

Finally, how did you hear about us or who referred you to this website?

By entering my name below and submitting this Caregiver Application Form, I confirm that the information I have provided herein is correct and complete to the best of my knowledge, and I consent to the use of this information by A.A. Clara's Agency and its agents for the purpose of verifying the information and providing or facilitating the services I am requesting.

Electronic signature (enter your full name):

A.A. Clara's Nanny Agency, 138 - 2785 Cooperative Way, Vancouver, BC V6M 4S4, Canada

Tel. 604.255.3440 - Cell 604.833.4274 - Email