Employers Form

*required

*First Name *Lastname

Address

Telephone Home Work Mobile

Occupation email

SpouseFirst Name Lastname

Occupation email

I. FAMILY INFORMATION

a. Does either parent work from home ?

b. When is the best time to contact you ?

c. How many family members in your family ? ( include yourself )

d. What type of nanny / caregiver does your family require ?

Nanny ( child care ) Senior Care
Disability Care Housekeeper

e. Are you expecting ?

            If yes, when is the due date ?

f. Do you have any other hired helper / nanny ?

g. Is English the primary language spoken at home?

h. Are any other languages spoken ?

Please provide a short description of your day to day life / activities and any expectations you have for the caregiver you’d prefer to hire :

II. CHILDREN / SENIOR INFORMATION

1) Name
Date of Birth
Age   Sex

2) Name
Date of Birth
Age   Sex

3) Name
Date of Birth
Age   Sex

4) Name
Date of Birth
Age   Sex

III. WORKING CONDITIONS ( NANNY / CAREGIVER )

Live In: Full Time: Live Out: Full Time: Part Time:

Starting Date Duration of Contract

What salary do you offer ?

Days off Total of Weekly Hours

Number of Paid Vacation Days Paid Sick Leave

Work begins at AM and finishes at PM

IV. DUTIES AND RESPONSIBILITIES REQUIRED OF CAREGIVER

In addition to Child care / Senior care, the caregiver is required to do :

Housekeeping	Family laundry
Family meal preparation	Children's meal preparation only
Gardening	Food shopping
Driving of children to school	Run Errands
Pet Care	Tutoring

V. HOME INFORMATION

a. List of pets, if any

b. Does anyone smoke in the house ?

c. Will the nanny / caregiver be allowed to have visitors?

            d. Will the nanny / caregiver have :
                        Private bedroom       Private bathroom
                        Own TV                   Own Phone
                        Cable                        Internet Access
                        Other:

            e. Location of Home:
                        Rural                           Main Road
                        Quiet Residential          Busy Residential

            f. Approximate area of the home square feet

g. Number of bedrooms

h. Number of bathrooms

i. Other rooms:

Where did you hear about HELPING HANDS INTERNATIONAL
PERSONNEL NANNIES & CAREGIVERS AGENCY ?

Friends Phone Book Ads Referrals

Thank you for choosing HELPING HANDS INTERNATIONAL PERSONNEL
NANNIES & CAREGIVERS AGENCY in helping you locate a qualified and responsible caregiver.

We will do our utmost to meet and exceed your needs and requirements.

Name: Date:

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