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Client Enrollment
Your Information
First Name
Last Name
Home Phone
Mobile Phone
Work Phone
Work Ext
Email (Required for Billing)
Occupation
Work from Home?
Yes
No
Spouse Information
First Name
Last Name
Home Phone
Mobile Phone
Work Phone
Work Ext
Email Address
Occupation
Work from Home?
Yes
No
Address & Directions
Street Address
Address contd...(optional)
City
State
Kentucky
Indiana
Zipcode
Driving Directions (From a major highway or downtown Louisville)
Children Information
Child 1
First Name
Last Name
Gender
-- Choose --
Male
Female
Birthday
Child 1 (Describe your child including any special needs)
Child 2
First Name
Last Name
Gender
-- Choose --
Male
Female
Birthday
Child 2 (Describe your child including any special needs)
Child 3
First Name
Last Name
Gender
-- Choose --
Male
Female
Birthday
Child 3 (Describe your child including any special needs)
Child 4
First Name
Last Name
Gender
-- Choose --
Male
Female
Birthday
Child 4 (Describe your child including any special needs)
Child 5
First Name
Last Name
Gender
-- Choose --
Male
Female
Birthday
Child 5 (Describe your child including any special needs)
Household Pets / Animals
Do you have pets?
Dog
Cat
Other
Type of Provider
I am looking for...
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...
Type of Services Needed
I am looking for...
Meals
Household Chores
Laundry for Children
Transport Children
Homework
Arts & Crafts
Errands
Pet Care
Other services not listed above (please specify)
Additional Information
Is your home accessible by Public Transportation?
Yes
No
Will the provider be required to have CPR certification?
Yes
No
Would you object to a provider bringing his/her child to work?
Yes
No
Would you reimburse the provider mileage expenses when using their own vehicle to transport your family members?
Yes
No
Will you provide a vehicle for the provider to transport your family members?
Yes
No
How did you hear about us?
On the Web
Phonebook
Word of Mouth
Newspaper
Other sources not listed above (please specify)
Terms & Conditions
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 the 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, and candidate(s) presented by Sitters Service without full written consent of Sitters Service. You further agree any employment, or referral of any candidate(s) without such consent will result in your full payment of Sitters Service's permanent placement fee.
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. If I employ a worker on a referral from the Agency, in consideration of the referral, screening and support services provided by the Agency. I will use the services of the childcare workers referred by the Agency only when contracting through the Agency. 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 to be as effective as if execution of the Terms and Conditions were by a manually written signature performed by you, and these Terms and Conditions shall be to satisfy any writing requirements of any applicable law. Our stored copy of these Terms and Conditions shall be deemed to be the correct enforceable copy of these Terms and Conditions and you agree not to contest the admissibility or enforceability of these Terms and Conditions.
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