General Info   Last Name:  First Name:  Address 1: Address 2: Home Phone # Work Phone # Fax # E-mail: Seeking a Nanny, Housekeeper Or? Start Date: Live -In Or Out? In Out Permanent? Temporary? On-Call? Number of Children: Ages of Children: Job Description: Salary Being Offered: Days of Week Required: 1 2 3 4 5 6 7 Hours of Day Required: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Drivers License Required? No Yes Vehicle Supplied? No Yes For Caregiver's Use: Work Only or Both? Work Only Both Statutory Holidays To Be Worked? No Yes Vacation Pay Being Offered? No Yes Please describe the type of Caregiver you feel would be ideal?    Childcare Duties Direct Supervision? Plan Activities? Food Preparation? Feeding? Bathing? Dressing? Transportation? Caring for visiting friends? Helping Children with Homework? Other?    Child-Related Housekeeping Duties Straightening up children's rooms and toys? No Yes Making children's beds and changing linen? No Yes Vacuuming/ Cleaning floors in children's rooms? No Yes Cleaning children's bedroom? No Yes Doing children's bathroom? No Yes Shopping for children (Food, Diapers, etc.)? No Yes Other?    Other Housekeeping Duties Tidying Up? No Yes Family Meal Preparation? No Yes Cleaning Kitchen? No Yes Making Family's Bed/Changing Linen? No Yes Vacuuming/Dusting? No Yes Grocery Shopping/Errands? No Yes Pet/Plant Care? No Yes Other?

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