Welcome to our online Family Application form. Please fill in the fields below as completely and as accurately as you can. This information is private and confidential and is for our internal use only. Thank you.
* - indicates a required field
PARENT'S INFORMATION:
SPOUSE'S INFORMATION: Information must be provided for each person who will contribute to wages paid to the Caregiver or will provide instruction to the Caregiver.
First Name:
Last Name:
Middle Initial:
*Street Address:
*City:
*Province:
*Postal Code:
*Home Phone:
Cell Phone:
Relationship with the person(s) receiving care:
CHILDREN INFORMATION:
Child's Full Name:
Sex:
Age:
Hrs. in School Daily
1.
2.
3.
4.
5.
6.
Are you expecting?
Due Date:
Is the care required due to a disability or medical condition?
If yes, describe briefly:
ELDERCARE INFORMATION:
Elder's Full Name:
Sex:
Age:
Medical Needs/Health Condition:
1.
2.
HOUSEHOLD INFORMATION:
Number of Adults in the Household:
(includes children over 18)
Other Hired Domestic Help:
Please list your Pets (if any):
Location of Home:
Total Number of Rooms in Home:
Number of Bedrooms in Home:
Number of Bathrooms in Home:
Do you have a Swimming Pool?
Are you within walking distance (3 km) to:
A Church
Shopping Centre
Public Transportation
Is English the primary language spoken?
Please list any other languages spoken:
Please list your family's interests & hobbies:
POSITION REQUIREMENTS:
Schedule of Hours:
(eg. Mon-Fri 8-5 and Sat 10-4)
Will there be Overtime:
(over 44 hours/week)
Starting Date:
Length of Employment:
Do you require that the Caregiver
has a valid Driver's License?
Do you require that the Caregiver
has her own car?
Will the Caregiver be required to escort the cared for individual(s) to school, medical appointments, lessons, etc?
Special skills required:
(eg. swimming)
Do you prefer a:
Please indicate if you have a preference of Nationality(ies):
Will stand-by hours be required?
CAREGIVER'S DUTIES AND RESPONSIBILITIES:
In addition to childcare, the Caregiver will be expected to:
Perform light housekeeping
Full housekeeping
Do family laundry
Run errands
Prepare meals for the family
Children's meals only
Drive children to school
Pet care
Other:
DETAILS OF CAREGIVER’S ACCOMMODATION:
Caregiver’s accommodation must meet municipal building requirements and health standards set by the province. This includes a properly heated and ventilated private room with a lock, which therein provides living and sleeping facilities intended for human habitation with no visible or structural repairs required. The Employer must provide the Caregiver with independent access to the residence (for example, house keys, security code) where the Caregiver resides.
In a live-in situation, will the Caregiver have:
Private Bedroom
Private Bathroom
Own TV
Cable TV
Own Phone
Shared Bathroom
Radio
Internet Access
Description of Caregiver’s room and furnishings:
Other:
AVAILABILITY TO INTERVIEW CAREGIVERS
Typically the Caregiver interviews are conducted via a 3-way conference call between you, one of our trained interview specialists and the Caregiver, during which we ask the applicant a number of questions and then we prompt you at the end of each interview to introduce yourselves, let the caregiver know where you live, how many children you have and what would her job responsibilities be. We will discuss the results of each interview with you once they are all completed.
Please indicate your preference for interview times:
I am usually available to interview at (check off all available times):
9 pm Saturday Night
11 pm Saturday Night
9 pm Week Night
11 pm Week Night
QUESTIONS:
1. How did you hear about our agency? If you were referred by someone, please list their name.
2. Please, share any comments that you think would be helpful to us.
By checking the check-box on the left and clicking on the "Send Application" button below, I hereby certify that the information provided on the above Family Application form is true, and I agree to release and promise to hold SELECT NANNIES harmless for any act of the Caregiver. I also certify that I have read, understand and agree to be bound by the TERMS AND CONDITIONS which also form part of this Application.
I understand, that I am under no obligation to hire a Caregiver from Select Nannies Inc. by submitting this form, and that the initial portion of the placement fee of $1,395 is not due until the Caregiver has accepted our job offer and the Service Canada application is ready to be submitted to Service Canada. The remaining fee is payable just prior to the Caregiver's arrival into my home, given that she has received her work visa and has an arrival flight booked. I understand that I am responsible for the Caregiver’s recruitment and transportation costs, private health insurance coverage for up to three months and Workers’ Compensation costs. If the placement does not work out within the first three months, and the Caregiver leaves her employment or I terminate her, Select Nannies Inc. will replace one caregiver free of charge and waive the next agency placement fee, as long as I have complied with the terms of the work contract and the applicable labour laws. I will still be responsible for the replacement Caregiver’s recruitment and transportation costs according to the Federal requirements. Each subsequent placement is discounted 25% off the current placement fee. Price is subject to change at any time without prior notice.
If you are satisfied with the information you entered above, please click the "Send Application" button below to send your application directly to us. We will respond to you within the next 24 hours.
Your information will be kept private and confidential, and is for our internal use only. For more information on the privacy of your information please review our Privacy Policy.
