BOOK A NANNY/SITTER
If you have already completed your Family Information form, you may fill out this form to request a service.
Registration
Please visit our website to register with our agency if not completed yet; (higher fees apply to non-registered families)
Have you submitted our registration form and paid our $300 fee via our website?
Yes
No
Will Complete
Service Request:
Sitterworx Membership
Occasional Non-Membership
Other
First Name
*
Last Name
*
Email
*
Cell Phone #
*
Work Phone #
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Will you be using a gift card, coupon or credit?
Yes
No
Don't have one
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Service Request Info
Parent #1 Employer
Complete if using workplace benefit
Parent #2 Employer
Complete if using workplace benefit
Service Needed
*
Please Select
Sitterworx Membership
Occasional (Non-Membership)
Meet & Greet
(1) Week Trial
Number of Children
*
Start Date & Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
End Date & Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Additional Dates Needed? (Please list)
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Children Details
Child #1 Name
*
Child #1 Age and Gender
*
Child #2 Name
Child #2 Age and Gender
Child #3 Name
Child #3 Age and Gender
Child #4 Name
Child #4 Age and Gender
Greeter Name
*
Releaser Name
*
Relationship to care recipient(s)?
*
Requested Nanny Name?
If you have a desired provider you've used before please let us know. We will see if that person is available for your request
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Helpful hints to find care location?:
Will anyone be in the home during care?
*
Please Select
Yes
No
Any Pets in the Home?
Dog
Cat
Other
None
If there will be a pet in the home, please tell us what type and size (small, medium, large)
Who will be at the location?
When will they be at the location?
Permission for Medication to be administered?
*
Please Select
Yes
No
If you gave us permission to administer medicine, please sign below:
Clear
Any additional notes about care?:
By signing below, you agree to pay caregiver at specified rate by end of session:
Clear
Stage
Deal Name
Submit
Should be Empty: