Client Family Enrollment

First Name *

Last Name *

Home Phone *

Mobile Phone

Work Phone

Ext

Email *

Occupation *

Work from Home? *

Yes

First Name

Last Name

Home Phone

Mobile Phone

Work Phone

Ext

Occupation

Work from Home?

Yes

Street Address *

Address contd... (optional)

City *

State *

Zipcode *

Driving Directions * (From a major highway or downtown Louisville)

First Name *

Last Name *

Gender *

Birthday * (MM/DD/YYYY)

Describe child including any special needs

Evenings / Weekends / Occasional

Nanny (Full-time, Part-time, Live in/out)

Temp / Summer Nanny (Max 3 months)

Adult care

Trip Sitting / Overnight Stay

Describe preferred schedule...

Meals for Children

Household Chores

Laundry for Children

Transport Children

Homework

Arts & Crafts

Errands

Pet Care

Other services not listed above (please specify)

Is your home accessible by Public Transportation?

Yes

Will the provider be required to have CPR certification?

Yes

Would you object to a provider bringing his/her child to work?

Yes

Would you reimburse the provider mileage expenses when using their own vehicle?

Yes

Will you provide a vehicle for the provider to transport your family members?

Yes

Web search

Social Media

Word of Mouth

School Campus

At Work

TERMS OF ACCEPTANCE

By completing the online enrollment, you authorize Sitters Service to perform necessary search for suitable Providers.
You agree to the Sitters Service Fees including initial enrollment fee as described.
You agree to pay the Provider as described.
You authorize Sitters Service to disclose necessary information to the provider deemed necessary for the service.
You agree not to hire, or refer to others, any candidate(s) presented by Sitters Service without full written consent of Sitters Service.

YOUR AUTHORIZATION *

I authorize Sitters Service (the Agency) to act as a referral agency when I request services. I understand that the childcare workers referred by the Agency on temporary and permanent assignments are my employees and that the Agency is not their employer. I hereby agree to hold the Agency harmless of any and all loss, damage, destruction or accident claims which may arise out of or in connection with the rendering of any services by any worker referred by the Agency.

I have read and accept the terms and conditions.

This agreement and acceptance shall be considered as effective as if execution were by a manually written signature. Our stored copy of these Terms and Conditions shall be deemed the correct enforceable copy.

Enter your initials *

Client Family Enrollment

Your Information

Spouse Information

Address & Directions

Children Information

Child 1

Household Pets / Animals

Type of Provider

I am looking for...

Describe preferred schedule...

Type of Services Needed

I am looking for...

Other services not listed above (please specify)

Additional Information

How did you hear about us?

Terms & Conditions