Dubols Home Care wants to invite you to visit their web site. Offering both child and elder care services. Please visit us at

FAMILY INFORMATION

PARENTS:

Mother's Name (First/Last name):

Full Address:
Home Phone: Cell Phone:
Profession: Work Phone:
Marital Status: Married Single Divorced
Email:

Father's Name (First/Last name):

Full Address:
Home Phone: Cell Phone:
Profession: Work Phone:
Marital Status: Married Single Divorced
Email:

CHILDREN:

Name of Child	Age	Special Needs (please explain)

Does anyone in your home smoke? Yes No If so, do you allow smoking by others? Yes No

Do you have any pets? Yes No
Type/Number of pets:

Do you own or rent? Own Rent

What do you own or rent? condo town home single family apartment

ABOUT THE POSITION

What type of specialized nanny are you looking for?

Nanny/Child care: Housekeeper/Cleaner: Nanny/Housekeeper:
Babysitter: Other:

Age preference for nanny (25-35, 35-45, 45-55, 55-60):

What type of nanny are you interested in? Live in: Live-out:

If Live-in, will the nanny have their own room? Yes No

Is your home accessible to public transportation? Yes No (If so explain below)

Does the nanny need to have her own car? Yes No

If not, is a vehicle provided? Yes No
If yes, the car is an Automatic StickShift .

Will the Nanny travel with you? Yes No

Select the jobs you would like to Nanny to perform:

Handling the children? Yes No	Discipline your children? Yes No
Laundry for children? Yes No	Clean children's rooms? Yes No
Cook for the family? Yes No	Cook for the children? Yes No
Give baths? Yes No	Engage your children in educational activities? Yes No
Laundry for family? Yes No

Job start date:

*Salary Hourly/Weekly Rate:

Type Your Name: Type Date:

Signature: ________________________________________________________ Date: __________________

If submitting form via this online form, you will be asked to sign when visiting our office.

Additional notes or comments:

Please read the Terms & Conditions then place an "X" in the box if you agree.
You will not be able to proceed if you do not agree with the Terms & Conditions of the contract.

I AGREE with the Terms & Conditions of the contract. Yes No

View terms and conditions

A registration fee of $300.00 is needed to process your paperwork. All checks should be made out
to DUBOLS HOME CARE. We also take all major credit cards.

**Please note that the salary of the nanny depends on the number of children that the nanny would be responsible for.