Little cherub registration form v1
- 1. FAMILY REGISTRATION FORM Family details: Mother’s Name: _________________________________________________________________________ Mother’s Nationality: _____________________________________________________________________ Contact Telephone Number: Work __________________________________ Mobile ________________________________ Landline _______________________________ Mother’s Email Address (please use capital) ______________________________________________ Father’s Name: __________________________________________________________________________ Father’s Nationality: ______________________________________________________________________ Contact Telephone Number: Work _________________________________ Mobile _______________________________ Landline ______________________________ Father’s Email Address (please use capital) ________________________________________________ Family Address: _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ Any hobbies or family interests? _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ Do any family members smoke? _____________________________________________________________________________ _____________ Do you have any pets? If so, please specify _______________________________________________ Languages spoken in the household ______________________________________________________ Children’s Information: Name and Date of Birth of Children: Name of Child __________________ Date of birth __________________ Gender ________ Name of Child ___________________ Date of birth __________________ Gender ________ Name of Child ___________________ Date of birth __________________ Gender ________ Ethnic & Religious/ Background ___________________________________________________________ Child’s medication requirements: HANDLED WIT H CARE
- 2. _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ Child’s food intolerance: _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ Child’s allergies: ______________________________________________________________________ ____________ ______________________________________________________________________ ____________ ______________________________________________________________________ ____________ Please provide information about your child’s general routine: _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ Any additional Information you feel is important: _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ Nanny Requirements: Please circle: Do you need? Nanny Mothers Help Maternity Nurse Live in Live out Permanent Temp Full Time Part Time Desired starting date: ____________________________________________________________________ Salary offer: _________________________________ net / gross (please circle) Length of employment required (min/max): _______________________________________________ Tax is required to be paid by employers. The agency can provide you with full details on how to process Tax and National Insurance. Dates and times do you require your nanny/mothers help/Maternity Nurse to work? Monday Tuesday Wednesday Thursday Friday Saturday Sunday Times Please give details of duties you require the nanny/mothers help to undertake: HANDLED WIT H CARE
- 3. _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ Do you need a driver? Y N If so, will a car be provided? Y N Will you consider a male carer? Y N Will you require a carer with a first aid certificate? Y N Will you require a carer with childcare qualifications? Y N Will you require your carer to travel on holidays with the family? Y N If you require a live in nanny please give information about the accommodation provided (E.g. own bathroom, etc): ______________________________________________________________________ ____________ ______________________________________________________________________ ____________ ______________________________________________________________________ ____________ Do you employ other staff in your home? ______________________________________________________________________ ____________ ______________________________________________________________________ ____________ ______________________________________________________________________ ____________ Have you employed a nanny/mother’s help/Maternity Nurse before? (If yes, please comment on your experience) _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ ______________________________________________________________________ ____________ Additional Information: Do you give the Agency consent to advertise your position? Y N Do you consent for Little Cherub to give your details to potential candidates? Y N Please give us any other information you consider important for the agency to find the right candidate for you _____________________________________________________________________________ _____________ _____________________________________________________________________________ _____________ _____________________________________________________________________________ HANDLED WIT H CARE
- 4. I agree to engage Little Cherub as sole Nanny Agency benefitting from the discount rates (please tick the box if you wish to use this option) I hereby understand and agree to the terms and conditions and give my consent to the Agency to use my details. I also confirm the above information is correct Print Full Name: _____________________________________________________________________________ _____________ Position in household: _____________________________________________________________________ Signed: _____________________________________________________________________________ ______ Date: _____________________________________________________________________________ _______ HANDLED WIT H CARE