Family Registration
PERSONAL INFORMATION -
(
*
) required
*
Name:
*
Address:
*
City/State/Zip:
*
Phone:
Fax:
Business Phone:
Business Fax:
Cell Phone:
*
Email :
SPOUSES INFORMATION
Name:
Address:
City/State/Zip:
Phone:
Fax:
Business Phone:
Business Fax:
Cell Phone:
Email:
Please provide the following information regarding your children:
(
Include: Name/Sex/Age/Special and/or Medical Needs
/
1)
2)
3)
4)
5)
CAREGIVER INFORMATION
Live In/Live Out:
Select
Live In
Live Out
Full Time/Part Time:
Select
Full Time
Part Time
Start Date:
Expected Salary:
Please describe the expected schedule you will require your caregiver
to work each week:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
Will your caregiver be required to work any additional hours:
Select
Yes
No
Explain:
What kind of commitment are you looking for from your caregiver?:
If you require a live-in caregiver, what living arrangements would you provide?
Have you had a nanny or caregiver in the past?
Select
Yes
No
Please descibe the situation:
Will the nanny be required to drive the children?
Select
Yes
No
If so, will you be providing a car?
Select
Yes
No
Will you offer health insurance/benefits?
Select
Yes
No
If so describe:
Does your family have any pets?:
Select
Yes
No
What kind?
Do you have other domestic help?
Select
Yes
No
Will you require your caregiver to do any housework?
Select
Yes
No
Please describe
:
Will your caregiver be required to travel with the family or stay at home overnight
with the children?
Select
Yes
No
Does your caregiver need to be able to swim?
Select
Yes
No
Describe the qualities you desire most in a caregiver:
How did you hear about The Washburn Agency?
