One-Time Use Job Request & Billing Authorization Form
Tell us how to reach you...
Tell Us About Your Child Care Needs...
Dates/days and schedule of when care provider is needed
Name & address where care provider is needed
Tell Us About The Children...
Children's names, ages - special needs?
Your Credit Card Information...
Full Name as it appears on your credit card
Please enter the address at which you receive your credit card statement.
Please enter only numbers
Please enter Month and Year
*finish by agreeing to our Terms of Service... When you sign below and click on the 'submit' button we will have everything we need to continue working with your family. This is a 100% Secure Form utilizing 128bit SSL data encryption for your security and protection.
Agreement and Authorization
I understand that scheduling fees are due immediately upon the confirmed scheduling of a care provider per the job order I am placing.
The cost of non-member use of the service is: - $50 for the scheduling of one care provider for one day - $20 per day, per care provider, for each additional day of scheduling requested
I understand that I am the employer of each care provider and that I will pay each care provider directly, at the end of each day, the rate of pay I have agreed to with each care provider. If I fail to pay care provider directly as agreed, I autuorize Childcare Solutions to charge the credit card listed above for any amount(s) due care provider and to make payment to the care provider on my behalf.
I understand that I may cancel any scheduled service but that scheduling fees are NON-REFUNDABLE and cannot be refunded.