CHILDCARE SOLUTIONS

Family Registration Form and Agreement

This is a SECURE form.
It is SSL encrypted to protect your personal information.
* = required information

Did someone refer you to us? If yes, who?

(if you were not referred, how did you hear about/find us?)

tell us about you...

*Parent 1

First Name

Last Name

*Parent 1 is:
Mother Father

Parent 2

First Name

Last Name

Parent 2 is:
Mother Father

Home Address

*Street Address

*City

*State

*Zip Code

*Home Phone (###) - ### - ####

*Email Address we should reply to:

parent information...

Parent 1 Mobile Phone (###) - ### - ####

Parent 1 Work Phone (###) - ### - ####

*Parent 1 Email Address

Parent 1 Profession

Parent 1 Company Name

*Parent 1 Date of Birth MM/DD/YYYY

/ /

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

Parent 2 Mobile Phone (###) - ### - ####

Parent 2 Work Phone (###) - ### - ####

Parent 2 Email Address

Parent 2 Profession

Parent 2 Company Name

Parent 2 Date of Birth MM/DD/YYY

/ /

tell us about your household...

*Other than immediate family members,
does anyone else reside in your home? If 'yes', please describe:

Describe any pets you have in your home... are they friendly or aggressive?

Describe your housekeeping standards:

Do you keep a kosher kitchen?
Yes No

*Is anyone in your home a smoker?
Yes No

tell us about your needs...

*Position Start Date MM/DD/YYYY

/ /

Position End Date (if there is one) MM/DD/YYYY

/ /

Salary Range:

*Describe the specific Days and Hours of the work schedule, including daily start and end times - and the job duties to be performed:

Please describe your 'IDEAL' nanny:

What types of child care
have you employed in the past?

Any additional information that will help in the search?:

Describe your views on effective discipline:

If this is a LIVE-IN position, describe the accomodations you can provide a nanny:

*Has your household ever experienced any incidents of domestic violence or sexual abuse?
Yes No
If yes, please explain:

	Please select: Yes, No or Depends
	Y N D
Does nanny need INFANT EXPERIENCE?
Does nanny need SPECIAL SKILLS?
Does nanny need SPECIAL NEEDS experience?

Will nanny be PREPARING MEALS?
Will nanny be doing GENERAL HOUSEWORK?
Does nanny need to DRIVE?
Does schedule require FLEXIBLE HOURS?
Does nanny need to SWIM?

May nanny bring her OWN CHILD to work?
Can nanny be a SMOKER?

CHILDCARE SOLUTIONS