New Family Sign-Up Form

Application Fee: $200.00

Application Date:
Caregiver Start Date:
Duration of Position:
Full Time Part Time Amount of Hours:
Live In Live Out
First Name Last Name
First name Last Name
Home Street Address:
City: State:


Cell Phone (M): Cell Phone: (F):
Father Company: Position:
Phone: Fax:
Mother Company: Position:
Phone: Fax:
Child Profile: Please print on all pages regarding children information
Days/ Hrs of School
Interests and/or special needs for each child:
Describe interests: (park, movies etc.)
Duties and Responsibilities of the child care giver: (please check all areas that apply)
Light Housekeeping
Grocery Shopping
Care of pets
Children's Laundry
Parent's Laundry
Travel with family Laundry
Do you have regular house help? Frequency?
Type of pets:
Will running errands be required?
Will car be provided for the caregiver to run errands?
Will caregiver be required to use their personal car to run errands for the family?

If Yes, will individual be compensated for expense?

Will auto be provided for employees' personal use?
If meal preparation is required, describe frequency and what is expected:
Will additional evenings or weekends hours ever be required:
Will employee be left in charge of the household over night?
Briefly describe expected daily routine and main duties of the employee:
Employees Work Schedule:
Day of the Week
What can the caregiver expect to experience and enjoy in your home in caring for your child?
Are there any other persons living in your home?
Please provide name and relationship:
Will anyone be present with your caregiver (grandparent, children's friends)?
Qualifications of the caregiver:
What are the most important qualifications/ characteristics of a caregiver that would be a successful relationship with your family?
Description of Home / Neighborhood:
Total Rooms
Total Bedrooms
Total Bathrooms
Swimming Pool
Tennis Court
Close to Library
Close to Park
Close to Shopping
Live in Caregiver Information ONLY (answer yes or no below)
Separate bedroom for caregiver Separate bathroom for caregiver
Separate Apartment for the caregiver
Please answer the following:
I am willing to consider applicants to interview and possibly hire that drive no more than miles from location of position
Are you currently using other means of hiring a caregiver outside Family Care Solutions, Inc.? (i.e. Family placing their own add in news paper, another agency, other)
Please describe:
Check the following box that applies: Salary based on hours per week/day or other:
Hourly (see below for pay range)
Salary Range: Lowest $ to
Highest $
(i.e. Hourly: $10.00 - $13.00 gross OR Salary $400.00 - $500.00 based on 40-50 hrs/wk)
Overtime rate of pay per hour (if applicable)
Is this job year round:
Are there days known at the time of placement that the applicant will not be needed? (i.e. summer, spring break, other)
Paid vacation: Describe:
Paid holiday: Describe:
Family car provided: Describe:
Mileage compensation for use of caregiver's car:
Health Benefits: Describe:
Travel: Describe:
Use of phone: Describe:
Application Fee:
How did you learn about Family Care Solutions, Inc.?
Family Care Solutions uses a secure server (SSL) to encrypt your information for security and safety.
Card Holders Name:
Type of card:  
Credit Card Number:
Exp Date:  
CPU-code on the card:
Billing Address:
Zip Code:  
Placement Fee:
Please read below - and check the boxes and initial after reading and agreeing to the terms:
Part Time Placement: $1500.00 due upon hiring of applicant INT:
20 hours or less denotes part-time placement, Anytime during the service placement becomes more than 20 hours, payment of $650.00 will be due within 24 hours of the change.

Full Time Placement: $1900.00 due upon hiring of applicant INT:

Temporary, Short Term or Emergency Placement $30 per day. INT:
Temporary, Short Term or Emergency 24 Hour Placement $42 per day. INT:

Please discuss with placement specialist.

There will be a residual fee yearly of 15% if the nanny continues past one year. INT:

We offer a 60 Day Guarantee (one Caregiver will be provided free of charge within the first 60 days)
**Fees are non-refundable**
It is understood - if the placement fee is not received within 24 hours of hire date - the balance remaining will be billed on the Credit Card number above. INT:
Placement date is defined as: Employer's offer and applicant acceptance of position. INT:
Part Time defined as 20 hours or less; Full Time defined as More than 20 hours INT:
Also available - information pertaining to Nanny Cam - would you like information?
This Family Profile is designed to provide information for the appropriate applicant. If the family information should change, we reserve the right to modify the fee structure in accordance to the situation.


- Family Care Solutions Inc acts as a referral agency only and will not be the employer or employee in the placement process. The selection and employment of a Care Provider is solely the employers (family) responsibility.
- Family Care Solutions Inc is not liable for any loss, damage, injury or expense which the Employer or any other person may incur as a result of negligence or any wrongful act of the employee.
- Family Care Solutions Inc is not responsible for any documentation input incorrectly by any applicant on the Family and/or Nanny Profiles.

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Family Care Solutions
233 South Main Street, Plymouth, MI 48170
Phone: (734) 459-6930 | Fax: (734) 459-2091