Employed outside the home?
Employed outside the home?
Helpful
Details About Your Family and Your Needs
Are you expecting a new baby?
If yes, what is the estimated date
of birth?
Are you looking for a full-time caregiver?
For how long will you be needing
a caregiver?
What would be the preferred start date?
What would be the preferred end date (if applicable)?
Would the caregiver live with you
in your home?
If you are looking for a live-in caregiver, briefly describe the living space you will provide: bedroom, private or shared bathroom, phone line, television, etc.
Does anyone else live in the home
with the parents and children listed above? If so, please
indicate name, age, and relationship.
Describe the area you live in (urban, suburban, rural) and proximity to public transit, shops, movie theatres, etc.
Proposed gross weekly salary or hourly
wage:
What would be the caregiver's regular
working days?
What would be the caregiver's regular
working hours?
If the schedule is likely to be irregular,
please explain:
Do you need a caregiver who can drive?
If yes, are you willing to provide
a vehicle?
If yes, is it automatic or standard?
What benefits, if any, will you offer the caregiver?
Will the caregiver be responsible for preparing meals?
What housework, if any, will the caregiver
be required to do?
Do you
have pets? What kind(s) and how many?
Will the caregiver be responsible for animal care?
Is smoking permitted in the home?
What qualities are most important to you in a caregiver?
What previous experience with childcare
/ care for the elderly / care for persons with disabilities
do you require?
How many caregivers have you had in
the past?
Do you need help doing Payroll?
Please feel free to elaborate on any
of the above if you wish, or describe any other needs of
your family.
Finally, how did you hear about
us or who referred you to this website?
By entering my name below and submitting this Family
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):