First Name
Last Name
Middle Name
Address
Street
City
Province
Country
Postal Code
Cell Phone
Home Phone
Work Phone
Email Address
Contact Method How would you like to be contacted?
Cell
Work
Email
Mail
What type of Caregiver do you require?
Child Care
Elderly Care
Part Time
Baby Sitter
Housekeeper
Select the responsibilities you require.
Do full house keeping
Do family laundry
Do light house keeping only
Drive children to school
Prepare meals for family
Provide pet care
Bathe the children /Elderly clients
Do arts and crafts with the children
Date you would like the Caregiver to start:
Name(s) of your Children or Elders requiring care:
Date of Birth /Age(s) and gender(s) of your children:
Number of hours required per week.
Rate Per hour
per week
per month
Describe the condition of the clients to be cared for:
Description of the house and household (number of rooms, household members, pets)
By submitting this form, you certify that the information provided in this application is true and accurate to the best of your knowledge.
