Client Registration Form

Client Registration

East Green Childcare Services

Client Registration Form

Your Family Details
Mother's Name:
Father's Name:
Home Address:
Home Tel No:
Home Fax No:
E-Mail:
Family Religion:
Mother's Occupation:					Full Time Part Time
Mother's Work Tel No.:					May we contact you at work? Yes No
Father's occupation:					Full Time Part Time
Father's Work Tel No.:					May we contact you at work? YesNo
Your Children

Are any of the children vegetarians?
Would you consider employing a non-vegetarian?					YesNo
Do any of your children have any special needs or requirements?
Is a new baby expected?
Other Household Details
Do you employ any other staff in your household?
Are there any family pets?
Will the carer be expected to help with pets?					YesNo
Family hobbies or interests:

Your Child Care Needs
Do you require a:	Nanny	Nanny/Housekeeper		Maternity Nurse
(please indicate [X])	Parent's Help	Babysitter		After School Care
Do you require a specific qualification?
Do you require a non-smoker?			YesNo
Is yours a non-smoking household?			YesNo
Would you consider a nanny with their own child?			YesNo

Transport Details
Do you require a driver?					YesNo
Will a car be provided?					YesNo
If so, will it be available outside working hours?					YesNo
Are you prepared to fund the upkeep of a carer's own car?					YesNo

Nursery Duties Expected of Carer
Wash and iron children's clothes:					YesNo
Clean and keep tidy children's bedrooms and bathrooms:					YesNo
Prepare children's meals:					YesNo
Clean playroom or dayroom:					YesNo
Clean kitchen after use:					YesNo
Keep toys and equipment in order:					YesNo
Shopping for family:					YesNo
Sole charge / shared care:					SoleShared
Any other duties, please give details:

Carer's Accommodation and Facilities
	Own room	Single	Double
(please indicate [X])	Own Bathroom	Television	Video
Please give details of any other facilities:

Employment Details
Is the position live-in or daily?			Live-in Daily
Do you require the carer to make alternative living arrangements for days off?			Yes No
Is the position permanent or temporary?			Permanent Temporary
Do you require weekend work?			Yes No
Will you give time-off in lieu?			Yes No
Proposed length of employment (minimum):
Salary offered:			£ Net per week
Is the salary negotiable?			Yes No
Hours of work:
Days off:
Annual leave:			Days per year
Have you employed a carer before?			Yes No
When is the position to commence?
Are there any family circumstances that the agency should be aware of?
Any Other Information
Please use this space to provide any other information:

This employment form is strictly confidential, under no circumstances will we allow any other person to obtain information from it other than prospective candidates or employees of East Green Child Care Services.
And Finally...
How did you hear about East Green Child Care Services?
I have read, understood and agree with the terms and conditions of East Green Child Care Services.