INFORMATION FORM

(Please Print, Complete and email to: cs@kidsathome.ca)

Fax: 1-833-548-0008

 

MOTHER’S FULL NAME:  ________________________________________________

FATHER’S FULL NAME:    _______________________________________________

 

MOTHER’S ADDRESS & PH:  ____________________________________________

FATHER’S ADDRESS & PH:  _____________________________________________

 

SERVICES REQUIRED:

¨ Live-in                   ¨ Live out                 ¨ Combination (state) ___________________

 

JOB TITLE:

¨ Nanny                                                                   ¨ Baby-sitter

¨ Doula                                                                     ¨ Day Home

¨ House keeper/House Manager                                    ¨ Maid

 

NO OF CHILDREN REQUIRING CARE:  ______________

AGE GROUP OF CHILDREN REQUIRING CARE:

¨ 0 to 18 Months (Infants)             ¨ 19 Months to 3 Years (Toddlers)

¨ 3 to 6 Years (Preschoolers)       ¨ 6 Years to 12 Years

 

TYPE OF SERVICE REQUIRED:           

¨ Temporary (until) ______________________ 

¨ Full-time                ¨ Part-time                ¨ Occasional           ¨ Emergency/Back-up

DAYS:

¨ Sunday                 ¨ Monday                 ¨ Tuesday                ¨ Wednesday         

¨ Thursday               ¨ Friday                    ¨ Saturday               ¨ Week-ends only

 

SHIFT: (from) __________________   (to) _____________________

 

START DATE:  _______________ STARTING WAGE (per hour/month):$ _________

 

LANGUAGES SPOKEN IN THE HOME:

¨ English                  ¨ French      

¨ Spanish                ¨ Other _______________________

 

DESCRIBE ANY SPECIAL NEEDS SITUATION OF CHILDREN REQUIRING CARE: 

____________________________________________________________________

____________________________________________________________________

 

SPECIAL REQUIREMENTS FOR THE JOB:

¨ Language             ¨ Child Care Training        ¨ Experience:  (minimum) __________

¨ Child Care Certification             ¨ Child Care Accreditation                        ¨ First Aid & CPR  

¨ Driver’s License   ¨ Vehicle      ¨ Other: (explain) ___________________________

 

SIGNATURE: (1) _______________________________________________________

SIGNATURE: (2) _______________________________________________________

 AGENCY:  ____________________________ DATE: ­_________________________

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