Nanny Elderly Application Form

Nanny Application (Elderly)

Yes No

Are you looking for?

Live-in Live-out Part-time Full-time

Long term temp placement (2-6 months)

Short term temporary placement (less than 2 months)

Please provide the following contact information: (All field required)

Name (First,Last)

Email (required):

Current Address
Street Address
Suite/Apt #
City, Province
Zip/Postal Code
Country
Daytime Phone
Evening Phone
Cell Phone

Permanent Address
Street Address
Suite/Apt #
City, Province
Zip/Postal Code
Country
Daytime Phone
Evening Phone
Cell Phone

Please provide the following personal information: (All fields required)

Sex	Male Female
Nationality
Date of Birth
Place of Birth
Marital Status
Any Dependents?
What is your Status in Canada?
Present Occupation
SIN # (if avail)

Please describe your Education & Training

How is your English?

Excellent Very Good Good Fair

What duties are you willing to do? (Please check all that apply) (All fields required)

Driving meals meals for family housekeeping

pet care laundry groceries ironing

occasional babysitting caring for elderly/handicapped traveling

Do you have any siblings? (if yes how many)
Do you have a drivers license?	Yes No
If yes, for how long?
Do you have a clean criminal record?	Yes No
Have you had a criminal record check?	Yes No

Do you have any Allergies?	Yes No
If yes, please describe
Are you First Aid certified?	Yes No
Are you CPR certified?	Yes No
If not certified are you willing to?	Yes No
Do you like pets?	Yes No
Do you swim?	Yes No
Do you smoke?	Yes No
If yes, how many cigs daily?
Do you like outdoor sports?

Please give us a brief description of your elderly or care experience

Please describe your Hobbies and Interests

Ages Preferences
Do you prefer placement in a	city suburb small town rural area

Information about Present and Previous Employers (Most current first) (All fields required)

#1

Name of Employer
Address of Employer
Phone # of Employer
Number of Children
Date you worked for the family
What were your activities w/the children?
Describe your duties
Reason for leaving

Name of Employer
Address of Employer
Phone # of Employer
Number of Children
Date you worked for the family
What were your activities w/the children?
Describe your duties
Reason for leaving

Name of Employer
Address of Employer
Phone # of Employer
Number of Children
Date you worked for the family
What were your activities w/the children?
Describe your duties
Reason for leaving

Any friends or relatives in Canada? (please explain)
Can we check your references?
How is your general health?
Do you have a valid passport?
Can you sign a contract (how long)?
When can you start to work?
Have you previously applied for a work permit in Canada? (results)

How did you hear about Happy Kidz Agency?

Terms & Conditions

1. These Terms and conditions shall represent a legally binding contract between HAPPY KIDZ CAREGIVERS and the caregiver.
2. All correspondence and records shall be confidential and remain the property of the Agency. Information supplied by the Agency is confidential and is accepted by the caregiver on the condition that such information will not be disclosed to any third party.
3. Should a caregiver affect any form of introduction, direct or indirect, of a client to a third party, or pass on any details resulting in permanent, temporary or part-time employment, the caregiver will be responsible for the full placement fee. If a caregiver accepts a position referred to and/or provided by the client or referred to by the client either in their home or third party home, caregiver will be responsible for the full placement fee.
4. The Agency accepts no liability of any kind for any kind for any inconvenience, loss or damage of property, or any loss or injury howsoever arising directly or indirectly from any act or omission of any applicant introduced by the Agency even if such an act or omission is negligent or fraudulent or reveals dishonesty.
5. The caregiver agrees to notify the Agency immediately an engagement has been and to supply details to the Agency of the date of commencement and length of employment and agreed wages.
6. Should a short-term engagement be extended by the Client, or by any applicant be re-arranged at any future time, the appropriate additional fee shall become payable. The Agency must be notified immediately of any such changes.
7. Should any applicant recruited as an evening babysitter be employed for daytime work, the agency must be notified immediately.
8. The agency does not employ caregivers introduced and any contracts of employment entered into between the client and the caregiver are between those persons directly. The client is responsible for complying with all employment, fiscal and other relevant legislation.
9. It is the caregiver's responsibility to notify the agency when accepting a job. If the caregiver fails to report to any confirmed jobs, she will face disciplinary measures, which may include suspension from the Agency.
10. If the caregiver becomes ill or if an emergency arises, she must contact Happy Kidz Caregivers immediately. Under no circumstances is a caregiver to pass on a job without the consent of Happy Kidz Caregivers. (babysitting only)
11. Caregivers who do not give the Client at least 24 hours notice prior to canceling a job will be suspended. (babysitting only)
12. Caregiver are employed solely by the Client and are not employees of the Happy Kidz Caregivers. Caregivers are independent contractors and will not be give a t4 at the end of the year and are solely responsible for paying their own taxes. (only applies to babysittings)
13. Happy Kidz Caregivers makes no representations to caregivers or clients concerning the nature of the service provided. The Client and caregiver acknowledge that Happy Kidz Caregivers is not responsible for, and will be held harmless against, any injury, loss, or other damage arising from or related in any manner to the Client or caregiver's use of the Happy Kidz Caregivers Agency.
14. If a caregiver knowingly deceives Happy Kidz caregiver by accepting employment within 1 yr of last booking with client and without the knowledge of Happy Kidz caregivers, the caregiver can and will be held responsible for all outstanding fees regarding agency placement/hourly rates. It is required that the caregiver inform Happy Kidz caregivers immediately when they are offered additional employment from clients. If nanny cancels employment after the contract has been signed and/or before commencement of nanny starting to work or start of orientation a $250 administration fee will be charged to the nanny and payable to Happy Kidz within 5 business days.

This agreement is binding under and subject to the laws of the Province of British Columbia, and is understood and accepted by the undersigned party.

I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND AND AGREE TO THIS CONTRACT IN ITS ENTIRETY. THIS AGREEMENT IS BINDING AND SUBJECT TO THE LAWS OF THE PROVINCE OF BRITISH COLUMBIA, AND IS UNDERSTOOD AND ACCEPTED BY THE UNDERSIGNED PARTY. ANY LEGAL FEES AND COURT COSTS INCLUDING REASONABLE ATTORNEY'S FEES INCURRED IN COLLECTING ANY MONIES DUE TO HAPPY KIDZ CAREGIVERS AT ANY TIME WILL BE THE SOLE RESPONSIBILITY OF THE CAREGIVER. SHOULD ANY TERMS BE BREACHED IN THIS AGREEMENT (IE. PLACEMENT IS ACCEPTED WITHOUT THE CONSENT OF THE AGENCY) BY THE APPLICANT. FULL AGENCY FEES + $500 BREACH OF CONTRACT FEE WILL BE CHARGED ON TOP OF ALL COLLECTION AND COURT RELATED FEES.

By submitting this application all Terms and Conditions are accepted in full

I hereby certify that I have answered the above questions to the best of my knowledge and belief

Date
Signature

Nanny Elderly Application Form

Happy Kidz Caregivers. Revised: September 09, 2008

Happy Kidz Caregivers.
Revised: September 09, 2008