If you are interested in employing a caring individual from Canada or overseas to help provide care for your family, or would like more information, please complete this Family Application Form.

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

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
Name
 
Age
Special needs (if any)
Male Female
Male Female
Male Female
Male Female
Male Female
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?
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):
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