Inquiry Form
Please give us information regarding your need
Basic Info
First Name
*
Last Name
*
Parent #2 First Name
Parent #2 Last Name
Contact Phone #
*
Please enter a valid phone number.
Email
*
example@example.com
Parent #2 Cell Phone
Please enter a valid phone number.
Parent #2 Email
example@example.com
Language(s) spoken
*
City & State Care Needed in
Soon/Future Care
*
Immediate
Future
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you willing to undergo a security check for you and the adult members of your household consisting of supplying character references for us to check?
*
Please Select
Yes
No
Maybe
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Backup Care
Have you used one of our caregivers for back-up care from any of the following?
*
Bright Horizons
Care.com
LifeCare
Corporate Care Solutions
None
Service Type
Provider Type(s) Needed
*
Nanny
Sitter
Household Manager
Housekeeper
Mother's Helper
Type of Service(s) Needed
*
Full-time Permanent
Part-time Permanent
Temporary
Occassional
Summer Care
Which of the following do you currently employ or plan to employ?
Nanny
Babysitter
Housekeeper
N/A
Type of Service(s) Needed
*
Permanent
Full-time
Part-time
Temporary
Occassional
Before & After School Care
Before School Care Only
After School Care Only
Summer Nanny
Live-In
Live-Out
Overnight (Permanent)
Overnight (Temporary)
N/A
Other
Other Service Type(s)
Event Sitter (Conference/Party)
Wedding Sitter
Special Needs Nanny or Sitter
Corporate Sitter (Employee HR Benefit)
Corporate Sitter On-Site
Transportation (4 hr. min.)
Reference Check Only
Background Check Only
Specialty Services
Newborn Care Specialist
Teacher
NCS
(Newborn Care Specialist)
Do you require Any of the following?
Certified by an Accredited NCS Training program
RN
LPN
No Certification
Nanny Share
Do you want to Nanny-Share?
Please Select
Yes
No
If Nanny-Sharing* Do you have a family to share with?
Yes I have a family
No, I do not have a family
How many families will be sharing a nanny?
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Service Details
Approximate Start Date
*
Approximate End Date
*
Start Time of Care
*
End Time of Care
*
Which day(s) will you need care or other service?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Unsure
How long do you anticipate using a provider?
*
occassional
one-time
under 1 month
1-3 months
1 year
2 years
2-5 years
Children Details
How many children need care?
1
2
3
4
5+
n/a
Check age(s):
1-3 Months
6-12 Months
12 - 24 Months
2 yrs. - 4 yrs.
5 yrs. and above
Child #1 Full Name
*
Child #1 Age and Gender
*
Child #2 Full Name
Child #2 Age and Gender
Child #3 Full Name
Child #3 Age and Gender
Child #4 Full Name
Child #4 Age and Gender
Is your child enrolled in public or private school?
*
Yes
No
What type of learning will your child engage in?
In-person
On-line
Hybrid
Homeschool
Unsure
If your child is diagnosed with a learning disability please specify here
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Caregiver Preferences
Will caregiver need to drive during care on occasion?
Yes
No
Maybe
Will caregiver have use of family's vehicle for transporting the children?
Yes
No
Will caregiver need to administer medication on occasion?
Yes
No
Maybe
Will you pay mileage Reimbursement for care related travel?
Yes
No
N/A
What kind of cooking and food prep do you want your nanny to handle?
Will nanny be expected to do house chores for the family
Yes
No
Occasionally
If house chores will be expected, list them; (additional fees will apply)
Cleaning Kitchen
Cleaning Bedrooms
Cleaning Bathrooms
Cleaning Common Areas
Dusting
Vacumming
Emptying Trash
Grocery Shopping
Other
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ADDITIONAL QUESTIONS
What is your family's childcare philosophy or parenting style?
Do you have pets?
Yes
No
If you have pets, will caregiver need to walk & feed them?
Yes
No
Maybe
Does your family currently employ a housekeeper?
Yes
No
Have you hired a nanny, babysitter, housekeeper or other provider before?
*
Yes
No
Currently employ a nanny
Currently employ a babysitter
Currently employ a housekeeper or cleaning service
How much have budgeted to pay a nanny, babysitter, housekeeper or other provider?
$18 - $20
$20 - $25
$25 - $50
Other
How many paid vacation days will nanny receive?
5
10
15
20
None
Other
How many paid sick days will nanny receive?
*
3
5
10
None
Other
Which items will you include as benefits for the provider?
*
Paid Time Off
Health Insurance stipend
401K
Tuition Reimbursement
Life Insurance
Disability Insurance
Flexible Spending Account
Relocation Assistance
Professional Development
Other
None
How many paid personal days will nanny receive?
*
1
2
3
4
5
None
Other
How many paid holidays will nanny receive?
*
5
6
7
8
9
10
11
12
None
Other
How would you prefer us to reach out to you?
*
Phone Call
Email
Text
What is the best time(s) for a placement specialist to reach you?
*
Morning
Afternoon
Evening
Weekday
Weekend
Other
Have you used a non web-based agency before?
*
Yes
No
How did you hear about our agency?
*
Google Search
Yelp
Care.com
TV Commercial
Website
Referral
Other
Will you give the provider a clothes stipend if a dress code is required?
Please Select
Yes
No
Maybe
Would you consider allowing caregiver to bring her child to work if suitable?
Please Select
Yes
No
Maybe
What dress requirement do you have for the provider?
If referred, please give us the name of the person who referred you:
Please give us any further details concerning your need if applicable or any other special requirements:
Covid-19 Considerations
Thank you!
Someone will contact you soon~
Has your family been vaccinated against Covid-19?
Please Select
Yes
No
Other
Rather Not Say
Will you require the provider to wear a mask while in your home?
Please Select
Yes
No
Maybe
Does your caregiver need to be vaccinated against Covid-19?
Please Select
Yes
No
Maybe
Soft Contact?
Please Select
Yes
No
Company
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