Application Form For Families

About the Mother

Family name:

Given name(s):

Work phone #:

Cell phone #:

Email:

Employed outside the home?

Yes     No

About the Father

Family name:

Given name(s):

Work phone #:

Cell phone #:

Email:

Employed outside the home?

Yes     No

Your Home Address

Street address:

City:

Province:

Postal code:

Home phone #:

Fax (if available):

Children in your family

Helpful Details About Your Family and Your Needs

Are you expecting a new baby?

Yes     No

If yes, what is the estimated date of birth?

Are you looking for a full-time caregiver?

Full time     Part time

For how long will you be needing a caregiver?

Short term     12 months or longer

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?

Yes ("live-in")      No ("live-out")

What is your home like?

House/Townhouse     Condo/Apartment

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?

Mon  Tue  Wed  Thu  Fri  Sat  Sun

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?

Yes     No

If yes, are you willing to provide a vehicle?

Yes     No

If yes, is it automatic or standard?

Automatic     Standard

What benefits, if any, will you offer the caregiver?

Medical   Car reimbursement   Sick leave

Will the caregiver be responsible for preparing meals?

Breakfast  Snack  Lunch  Dinner

What housework, if any, will the caregiver be required to do?

Doing laundry
Vacuuming
Washing floors
Dusting
Tidying children's rooms
Tidying master bedroom
Cleaning bathrooms
Other:

Do you have pets? What kind(s) and how many?

Will the caregiver be responsible for animal care?

Yes     No

Is smoking permitted in the home?

Yes     No

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?

Why did they leave?

Do you need help doing Payroll?

Yes     No

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?

Electronic signature (enter your full name):