Application Date:
Caregiver Start Date:
Duration of Position:
Full Time
Amount of Hours:
Mothers
Fathers
Home Street Address:
City:
State:
Zip:
Phone:
Email:
Cell Phone (M):
Cell Phone: (F):
Occupation:
Father Company:
Position:
Phone:
Fax:
Mother Company:
Position:
Phone:
Fax:
Child Profile: Please print on all pages
regarding children information
Interests and/or special needs for each
child:
Duties and Responsibilities of the child
care giver: (please check all areas that apply)
Driving
Children's Laundry
Do you have regular house help?
---
YES
NO
Frequency?
Type of pets:
Will running errands be required?
---
YES
NO
Will car be provided for the caregiver to run errands?
---
YES
NO
Will caregiver be required to use their personal car to
run errands for the family?
---
YES
NO
If Yes, will individual be compensated for expense?
---
YES
NO
Will auto be provided for employees' personal use?
---
YES
NO
If meal preparation is required, describe frequency
and what is expected:
Will additional evenings or weekends hours ever
be required:
---
YES
NO
Explain:
Will employee be left in charge of the household
over night?
---
YES
NO
Explain:
Briefly describe expected daily routine and
main duties of the employee:
Employees Work Schedule:
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?
---
YES
NO
Please provide name and relationship:
Will anyone be present with your caregiver (grandparent,
children's friends)?
---
YES
NO
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
Swimming Pool
Live in Caregiver Information ONLY (answer
yes or no below)
Separate bedroom for caregiver
---
YES
NO
Separate bathroom for caregiver
---
YES
NO
Separate Apartment for the caregiver
---
YES
NO
Please answer the
following:
I am willing to consider applicants to interview
and possibly hire that drive no more than
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)
---
YES
NO
Please describe:
Compensation
Check the following box that applies:
(see below for pay range)
Salary Range:
Lowest $
(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:
---
YES
NO
Are there days known at the time of placement that the applicant
will not be needed? (i.e. summer, spring break, other)
Describe:
Paid vacation:
---
YES
NO
Describe:
Paid holiday:
---
YES
NO
Describe:
Family car provided:
---
YES
NO
Describe:
Mileage compensation for use of caregiver's
car:
---
YES
NO
Describe:
Health Benefits:
---
YES
NO
Describe:
Travel:
---
YES
NO
Describe:
Use of phone:
---
YES
NO
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:
VISA
MASTER CARD
Credit Card Number:
Exp Date:
CPU-code on the card:
Billing Address:
City:
State:
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:
Full Time Placement: $1900.00 due upon hiring
of applicant INT:
Temporary, Short Term or Emergency Placement $30 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) INT:
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?
---
YES
NO
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.
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