SERVICE REQUEST FORM: CHILDCARE

Service Request: Childcare Services

1. CONTACT INFORMATION

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Postal Code

Country

Parent Status:

2. Care Information

Please select the type of care that you need:

Childcare (1 or more children)

Housework (cleaning and/or cooking)

Please list your children below: (Click on the + and - button to add or remove children.)

Gender of child:	Age of Child:	Is this child special needs?

Are you currently expecting a child?

Yes

What type of living arrangement are you looking for?

What type of worker are you looking for?

Please explain your needs for us:

Do you need care on weekends?

Gender of Caregiver that you're comfortable with:

Male

Female

Any comments to help us recruit for you?

When do you need a Caregiver?

3. Home Environment

Home type:

Size of home (living area):

Is there a swimming pool on the premises?

Yes

Do you have any pets in the home?

Yes

Please list your pets (if any) below: Click on the + and - button to add or remove pets.

Type of pet:

4. Additional Care Information

Please provide us with an overview of all duties and tasks required in your home:

Do you require your Caregiver to travel with you on family vacations?

Yes

I agree and permit SINKA STAFFING SERVICES to correspond with me by phone and/or email.

SERVICE REQUEST FORM: CHILDCARE

1. CONTACT INFORMATION

2. Care Information

3. Home Environment

4. Additional Care Information

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