Employers Registration

PERSONAL INFORMATION
Name(s):
Email:
Address:
City:
Province:
Postal Code:
Phone
Home: Cell: Fax:
Best time to call: Which Number? Home Cell
Occupation:
Spouses Occupation: (if applicable)
Number of Children: Elders:
Age of Children: Elders:
Language(s) spoken at home:
Are there any smokers in the home? Yes No
Any other Adults in the home?
Specify: 		Yes No
Have you had a Nanny/Caregiver before? Yes No
If Yes, is she/he currently working for you? Yes No
What is the anticipated date when you require your nanny/caregiver:
 
RESPONSIBILITIES (Check all that are applicable)
Child Care: Elder Care:
Disabled Care: Pet Care:
Housekeeping: Laundry:
Ironing: Carwashing:
Plan Meals: Prepare Meals:
Wash Dishes/Clean up: Trash Removal:
Shovel Driveway: Lawn & Garden:
Grocery Shopping/Marketing: Run Errands:
Take children/elder to and from appointments/activities/school:
Other: (specify - maximum 200 Characters - fills the box.)

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CAREGIVER REQUIREMENTS
Do you prefer:Full timePart timePermanentLive-inLive-outOn call
If part time please specify the days and hours:
Are you willing to pay overtime?
(over 44 hours/week count as overtime) :		 Yes No
Specify the days and hours to be worked:
Days off: specify: How much is your offered salary?
Do you have any preference of nationality?
If Yes, which one? 		Yes No
Gender? Male Female  
Do you require a valid driver's license? Yes No To own car? Yes No
Special skills?
Expected starting date? Length of employment?
Describe an ideal caregiver that fits your family's needs:
(maximum 200 Characters - fills the box.)

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Please give us a description of your lifestyle and the expectations you have for a caregiver:
(maximum 200 Characters - fills the box.)

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CAREGIVER ACCOMMODATIONS
Private room Private bath Locked
Private Phone Internet TV Vehicle provided
Allowed to use the home phone for long distance:
Allowed to accept visitors?
Will the caregiver have a curfew: Yes No What time?
 
HOME DESCRIPTION
Location: Rural Quiet Residential Busy Residential Main Road
Description of home: Number of bedrooms: Number of bathrooms:
Other rooms:
Other Comments:(maximum 200 Characters - fills the box.)

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Where did you hear about us?
Give us any comments that may help us be more effective:
(maximum 200 Characters - fills the box.)

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