TEMPORARY CHILDCARE NEEDS REGISTRATION
FAMILY INFORMATION FORM
Today's Date:     On Call Sitter Needed?
Dates Care Needed - From:     To:
How Did You Hear About Us:
Contact Name - Last: First:
Phones - Home: Work: Cell:
Fax: Best number to reach you:  
Spouse Name - Last: First:
Phones - Work: Home: Cell:
Email Address:
Service Location Address:
Service Location Phone:    Area of town: 
Major Cross Streets:
Home/Mailing Address:
City:     State:     Zip: 
Your Profession:
Your Employer:
Spouse Profession:
Spouse Employer:
(This information is helpful because your nanny will want to know a bit about you too!)
CHILD'S NAME:        BIRTH DATE:         SPECIAL NEEEDS/CONCERNS:
              
              
              
              
Nanny's Duties:
(Nannies are expected to care for all child related tasks - children's laundry, bedrooms, play area, etc.)
List Pets Kept Indoors:
Nanny Care for Pets?
List Others Living in Home:
Nannies Duties for Above:
Other Special Circumstances:
"On the Job" Driving:   Yes       No
Swimming with Children Required?   Yes       No
TEMPORARY SERVICES AGREEMENT
I,   (please type your name) (hereinafter referred to as the “client” or “I”) agree to use the services of Nanny Connection, (hereinafter referred to as NC) in the referral of a childcare, eldercare provider or housekeeper, (hereinafter referred to as an “employee” “applicant” “nanny” or “candidate”) to work in my household.

Agree to Pay: In consideration for the aforementioned referral, I will pay a referral fee (please see accompanying fee schedule) to NC. This fee is contingent upon my hiring a candidate that NC has referred to me. Signing or submitting (clicking on the Submit button) this contract in no way obligates me to hire a candidate from NC. I understand, agree and accept that all candidates’ profiles and files, which are received from NC, are the property of NC and the contents are confidential. I agree that I will not disclose to anyone the names, addresses, telephone numbers or vital information pertaining to any candidate. I understand that I am not to contact any candidate directly for the purpose of employment on a long-term or temporary basis without NC’s knowledge. If, within one year of the date of the original referral, I offer long-term or temporary employment to a candidate that NC has referred to me the stated referral fee will be due to NC. If I violate this provision and any information contained in the file is disclosed to a third party by me, and that third party hires the applicant, I agree to pay the placement fee of said applicant. In the event that NC presses suit to enforce this provision, then the prevailing party shall be reimbursed for court costs and reasonable attorney fees.

Receipt of Fees: Should I hire an employee through NC I understand that the referral fee is due when the offer is extended and accepted and it is required that payment is received at that time. I understand that I may prepay the referral fee by check or cash at the time of registration. If prepayment is not received, I authorize the use of my credit card as payment for referral. All fees paid are non-refundable. Referral fees are not deposited until I agree to employ the candidate.

Background Screening: A professional pre-employment screening firm performs NC’s searches. A multi-state criminal check is run on all nannies that are hired on a long-term or short-term basis. These checks are important tools in screening out undesirable care providers; however, no combination of background checks is 100% fail-safe.

References: NC verifies the employment history on each applicant. NC will begin a search only if the information below is completed and payment or credit card information is received. Since collection can be difficult, time consuming and strain the relationship between NC and our clients, NC asks for a Guarantee of Payment. By signing this agreement I authorize NC to charge the agreed referral fee to my American Express, MasterCard or Visa credit card account at the time of hire. This charge will not be made unless I have hired the candidate and I have been notified that NC will be processing the charge to my account. No charge will be made without notification unless NC becomes aware that the candidate is already working for me.

Client Acknowledgment and Release: NC is a referral service and does not maintain an employer/employee relationship with any candidate. NC will exercise its best efforts in referring the most suitable candidates but cannot make any guarantees; expressed or implied, regarding the performance of the person referred to me and subsequently employed by me. There shall be no additions, deletions or modifications made to this contract. I understand that NC does not have any control over the services provided by the candidate.

I release and discharge forever Nanny Connection, its respective officers, directors, agents and employees from all actions, causes of action, claims and demands for injuries, accidents, sickness and damages of whatsoever nature, whether known or unknown, which may be sustained by me or my dependent arising out of the performance or nonperformance of the candidate (my employee.) I, hereby agree to indemnify and save harmless NC from all injuries, losses, damages and expenses, should any claim, demand or suit be made by me on behalf of my child or children, ward or parent(s).

I understand the above statement regarding Guarantee of Payment. I authorize Nanny Connection to charge my credit card account if I hire an applicant from Nanny Connection. I also understand that submitting this form to Nanny Connection is the same as signing the form.
Please send me news and updates
PLEASE CHARGE MY REFERRAL FEE TO:
(Required information - You are on a secure server to protect you)
The Referral Fee will not be charged until the time you hire a babysitter

Credit Card: 
Card No: 
Name on Card: 
Verification Code:
  Exp. Date:  Eg:MM/YY
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Instructions
  1. Fill in form and submit it.
  2. You understand that this is a legally binding agreement and by submitting this form electronically is the same as signing the form.
  3. On receipt of this form we will begin your babysitter search.
  4. The referral fee will not be charged until the time you hire a nanny.