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Registration Form

Client Information:

Name: *
Occupation:
Employed By:
Cell Phone: *
E-mail Address: *
Spouse Name (if applicable):
Spouse Occupation:
Spouse Employed By:
Spouse Cell Phone:
Spouse E-mail Address:
Home Address:
City:
State:
Zip:
Home Phone:
Fax:

Interested In:

Nanny
Housekeeper
Elder Companion
Household Manager
Chef/Cook
Personal Assistant
Other:

If you checked Nanny:

Number of Children:
Child #1 Name:
Child #2 Name:
Child #3 Name:
Child #1 Age:
Child #2 Age:
Child #3 Age:
Child #1 Sex:
Male
Female
Child #2 Sex:
Male
Female
Child #3 Sex:
Male
Female
Child #1 Medical/Special Needs:
Child #2 Medical/Special Needs:
Child #3 Medical/Special Needs:

If you checked Elder Care/Companion:

Age:
Sex:
Medical Needs:

Schedule/Position:

Full Time
Part Time
Live In
Live Out
If live in: Please describe the living situation: (ie: private bedroom, private bath, separate/shared entrance.)

Please describe the expected schedule including start and end times:

Monday:

Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
Is there any flexibility in hours?

Job Duties:

(Check all that apply)

Nanny:

Childcare Only
Childcare/Light Housekeeping
Clean Up Kitchen
Empty Dishwasher
Keep Children's Room's Clean
Make Beds
Cooking (Please complete the cooking section)
Driving Children
Please describe your home: (ie: square feet, number of bedrooms/bathrooms)

Housekeeping:

Clean Kitchen
Make Beds
Dust
Vacuum
Clean Bathrooms
Wash Floors
Wash Dishes
Wash Clothes
Wash Linens
Iron Clothes
Iron Linens

Cooking:

Children's Meal's Only
Gourmet Cooking
Plain Cooking
Family Cooking
Family Serving
Menu Planning
Formal Serving
Any dietary or religious restrictions?

Household Management:

Supervise Staff
Hire Staff
Run Errands
Computer Skills?
Other duties required?

Other Criteria:

Non-smoker?
Yes
No
CPR Certified?
Yes
No
First Aid Certified?
Yes
No
Driver?
Yes
No
Must own their own car?
Yes
No
Do you have pets? Please describe:
Is there any pet care?
Yes
No
Any travel? Please describe: (ie: how often, required schedule, accommodations.)
Are there any languages spoken in your household besides English?
Is your home accessible via public transportation? If so, please describe:
Anticipated Start Date:

Compensation/Benefits:

Approximate salary range (please be specific).
Is a car provided?
Yes
No
Is the car available for use while the individual is off duty?
Yes
No
Holidays: Off and Paid?
Vacation: Number of weeks paid?
Other benefits offered: (ie: Health Insurance, Bonuses, Travel, Tuition Reimbursement, etc.)
Additional Comments?
How did you hear about The Washburn Agency?

* Required