This is a Printable Form Only! Click Here to Print this Form fill it out and send it back to the Boston Nanny Centre via mail (135 Selwyn Road, Newton, MA 02461) or fax (617-969-8401).

Name of Applicant ____________________________________ Date of birth ___________

________________________________________________________________________________
(Street No and Name) (City) (State) (Zip)

I hereby authorize you to provide the Boston Nanny Centre, Inc. with the information requested on this form regarding my physical and mental health. I also hereby give my permission to verify the below signature with the physician's office.

Applicant's Signature ____________________________________ Date ___________

--------------------------------------------------------------------------------

To be completed by the physician

The individual above is applying for a position as a childcare provider. She/he will be working with families and be responsible for their children. Some lifting of children, cooking, laundry, driving, and cleaning may be required.

In your opinion is this applicant free of disease and physical disabilities which would adversely affect the children and adults with whom the applicant is working or prevent the applicant from carrying out childcare/household duties?
Yes __No __ If no, please explain __________________________________________

In your opinion is this applicant free of mental or emotional problems that would be detrimental to the children and adults with whom she/he will be working?
Yes __No __ If no, please explain _______________________________________________

Massachusetts law requires a negative tuberculin test for any individual who works with children. Please include your test results below:
TB Test (Mantoux) ___ Negative ___ Positive __ Date Given ________

How long have you been the applicant's physician? ___________________________
Date of last physical exam? __________________________________________
Physician's name? ____________________________ Telephone __________________
Office Address? ______________________________________________________________
(Street No and Name) (City) (State) (Zip)

Physician's signature _____________________________________________________