Parents' Information
Mother's First Name:
Mother's Last Name:
Mother's Occupation:
Father's First Name:
Father's Last Name:
Father's Occupation:
Home Address:
City:
Zip Code:
Phone:
E-Mail:
Child 1
Name:
Age:
Date Of Birth:
	Any special needs/issues/concerns?
	School schedule/activities
Child 2
Name:
Age:
Date Of Birth:
	Any special needs/issues/concerns?
	School schedule/activities
Child 3
Name:
Age:
Date Of Birth:
	Any special needs/issues/concerns?
	School schedule/activities
Child 4
Name:
Age:
Date Of Birth:
	Any special needs/issues/concerns?
	School schedule/activities
Scheduling
Start Date:	Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2009 2010 2011 2012
Days:	Sunday   Monday   Tuesday   Wednesday   Thursday   Friday   Saturday
Hours:
Flexibility Needed:
Additional Information
	Do you travel for business?
	Yes   No
	Does either parent work from home?
	Yes   No
	Is driving required?
	Yes   No
	Do you provide a vehicle/mileage assistance?
	Yes   No
	Are there pets in your home?
	Yes   No
If so, please describe:
Salary Range:	(Please don't leave this blank or write "market." We are looking for your initial ideas. We will discuss this thoroughly during our phone consultation.)
Benefits:	Vacation   Paid Holidays   Personal / Sick Days   Assistance With Health Insurance
	Please tell us a little bit about your family:
	What qualities are most important to you in a caregiver?
	Who should we contact to schedule a thorough discussion of your familiy's needs?
	What is the best time to reach you?
	Please plan on 15 - 30 minutes for a detailed phone conversation.

 

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