Childcaregiver Request Form (Nanny/Sitter)

Please Enter the following information:
  • If the address of services needed is different from the Address of Residence, please provide it.
  • Date and Time Service Requested

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  • Please enter a value greater than or equal to 5.
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  • Please enter a value greater than or equal to 5.
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  • Please enter a value greater than or equal to 5.
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  • Please enter a value greater than or equal to 5.
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  • Please enter a value greater than or equal to 5.
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  • Please enter a value greater than or equal to 5.
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  • Please enter a value greater than or equal to 5.
  • Details of the Child/Children

  • Please note: caregivers cannot administer any medication at any time while caring for the child/children.
  • Please note: Caregivers cannot drop off or take the children outside of the location where the service is being provided.
    To become a Family Care Member and receive a discounted hourly rate please go to http://www.familycareoption.com,/applications fill out a family application and once registered, you will receive discounted hourly rates with your membership, guaranteed 24 hours a day / 7 days a week care coverage, monthly promotions and our Family Care Option newsletter.
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  • Payment Section

    Upon receiving the caregiver/sitter/nanny request form, a Family Caregiver Specialist will contact you to confirm your caregiver and email a caregiver/sitter confirmation with the caregiver/sitter profile attached for your review.
  • Cancellation: Cancellations received less than 24 hours from start time of the request, will incur a cancellation charge of 5-hour minimum.
  • Please sign your name and date in the box above.
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