Welcome to our online Family Application form. Please fill in the fields below as completely and as accurately as you can. This information is private and confidential and is for our internal use only. Thank you.

* - indicates a required field

PARENT'S INFORMATION:
*Your First Name: *Your Last Name:
Your Middle Initial:
*Street Address:
*City: *Province:
*Postal Code: *Home Phone:
Work Phone: Fax:
*Best time to contact you: Preferred contact method:
*Email Address:    
Occupation: Employer:
Days of Work: Hours of Work:
SPOUSE'S INFORMATION:
First Name: Last Name:
Middle Initial:
Occupation: Employer:
Days of Work: Hours of Work:
CHILDREN INFORMATION:
Child's Name: Sex: Age: Interests: Hrs. in School Daily
1.
2.
3.
4.
5.
6.
Are you expecting? Due Date:
Is the care required due to a disability or medical condition?
If yes, describe briefly:
ELDERCARE INFORMATION:
Elder's Name: Sex: Age: Medical Needs/Health Condition:  
1.  
2.  
HOUSEHOLD INFORMATION:
Number of Adults in the Household: (includes children over 18)
Other Hired Domestic Help:
Please list your Pets (if any):
Location of Home:
Number of Bedrooms in Home:
Number of Bathrooms in Home:
Do you have a Swimming Pool?
Is English the primary language spoken?
Please list any other languages spoken:
Please list your family's interests & hobbies:
POSITION REQUIREMENTS:
Schedule of Hours:
(eg. Mon-Fri 8-5 and Sat 10-4)
Will there be Overtime: (over 44 hours/week)
Starting Date: Length of Employment:
Do you require that the Caregiver
has a valid Driver's License?
Do you require that the Caregiver
has her own car?
Will the Caregiver be required to escort the cared for individual(s) to school, medical appointments, lessons, etc?
Special skills required:
(eg. swimming)
Do you prefer a:
Please indicate if you have a preference of Nationality(ies):
CAREGIVER'S DUTIES AND RESPONSIBILITIES:
In addition to childcare, the Caregiver will be expected to:
Perform light housekeeping Full housekeeping
Do family laundry Run errands
Prepare meals for the family Children's meals only
Drive children to school Pet care
Other:
DETAILS OF CAREGIVER’S ACCOMMODATION:
In a live-in situation, will the Caregiver have:
Private Bedroom Private Bathroom Own TV
Cable TV Own Phone Shared Bathroom
Other:
QUESTIONS:
1. Please, specify the need for a Caregiver to live in your home on a full time basis.
2. What specific efforts have been made to recruit a Caregiver up to now?
3. How did you hear about our agency?
4. Please, share any comments that you think would be helpful to us.
TERMS & CONDITIONS:
By checking the check-box on the left and clicking on the "SUBMIT" button below, I hereby certify that the information provided on the above Family Application form is true, and I agree to release and promise to hold A-PRO Caregivers & Nannies Inc harmless for any act of the Caregiver. I also certify that I have read, understand and agree to be bound by the TERMS AND CONDITIONS which also form part of this Application. I understand, that I am under no obligation to hire a Caregiver from A-PRO Caregivers & Nannies Inc; by submitting this form, and that the initial portion of the placement fee of $500 is not due until the Caregiver has accepted our job offer and the HRDC application is ready to be submitted to Human Resources. The remaining $300 is payable once the Caregiver arrives into my home.