Find A Home Buddy

*Date:

/ /

*Name/Client 1:

*Address:

*City:

*State:

*Zip:

*Home Phone:

- -

Work Phone:

- - x

Cell Phone:

- -

*Email:

*Occupation:

Marital Status:

Explain Other in next line

Explain other
marital status:

*Name/Client 2:

*Address:

*City:

*State:

*Zip:

*Home Phone:

- -

Work Phone:

- - x

Cell Phone:

- -

*Email:

*Occupation:

Marital Status:

Explain other
marital status:

*Describe your family:

*Does your family own
pets:

If yes, describe in next line

If yes, please
describe:


	Home Buddy Requirements

*What type of
position are you
looking for?:

Hold Cntrl key to
make multiple selections.
If other, please explain below

Explain "other"
postiion:

*What type of work
arrangement are you
looking for?:

Select Live-in or Live-out
or on-call and hold press
Cntrl to select duration

Days needed to work:

Days Home Buddy weeded:

Days needed to work:

Hold Cntrl Key to
make multiple selections

Hours required to
work from:

:	Explain below if necessary

Hours required to
work to:

:	Explain below if necessary

Start date:

/ /

Length of commitment
required:

*Please select all
the duties you need
your Home Buddy to
perform:

Hold cntrl Key to
make multiple selections

Explain "other"
duties:

(chars left: 255)

*Will your HomeBuddy
be required to
travel with the
family:

*Do you require your
HomeBuddy to be
bi-lingual:

*Does Either Parent
or any household
member work from
home?:

*Are you open to a
HomeBuddy who would
bring his/her own
children? :

*Are you open to a
Male HomeBuddy?:

*Do you require your
HomeBuddy to be able
to swim:

*Does your family own
firearms:

If yes, are they
locked in a gun
cabinet:

*Do you allow smoking
in your home:

*Is your home located
near public
transportation:

*Do you employ a
housekeeper:

If yes, how often
does he/she clean
the home:

Do you need your
HomeBuddy to Drive:

If yes, answer next 4 questions

You will supply a
car for HomeBuddy
for:

Select One

HomeBuddy will use
their own car:

If you pay for gas
you will pay:

How much will you
pay:


	The following questions are only for clients needing childcare. Skip to references if not needed

Names of Children,
Birthdate, Age & Gender:

(chars left: 255)

Enter information for
each child on a
seperate line.

Do any of the
children have
special needs or
health concerns:

Special Needs
Experience Needed:

Hold the Cntrl key to
make multiple selections

Please select all
Age Ranges/Multiples:

Hold the Cntrl key to
make multiple selections

What activities
would you like the
children to be
involved in with the
caregiver:

(chars left: 255)

What form of
discipline do you
feel is most
effective?:

(chars left: 255)


	References - Include Previous Childcare or Domestic Employess if Possible Please contact references to them know they will be contacted

Previous Childcare
of Domestic Employee
Reference 1 Name:

Employment Dates
From:

/ /

Employment Dates To:

/ /

May we contact:

Still employed:

Home Phone:

- -

Work Phone:

- - x

Cell Phone:

- -

City/State/Zip:

Was the childcare
provider employed:


	Character References (known for at least 2 years or longer)

*Character Reference
1:

*May we contact:

Home Phone:

- -

Work Phone:

- - x

Cell Phone:

- -

City/State/Zip:

Email:

*Character Reference
2:

*May we contact:

Home Phone:

- -

Work Phone:

- - x

Cell Phone:

- -

City/State/Zip:

Email:

Additional
information or
comments that will
help us make the
most compatible
match for you and
the HomeBuddy:

(chars left: 255)

*Are you working with
other agencies:

If so, who:

Who can we thank for
referring you to
HomeBuddies? (Please
be specific):

List "other" below

"Other" Thank You :


	Submission of this form indicates that all information is accurate to the best of your knowledge

Childcare
Child Laundry
Family Laundry
Child Bathing
Heavy Housekeeping
Organizational Projects
Plant Care
Pet Care
Cooking for Parties
Domestic Shopping
Running Errands
Domestic Secretarial Duties
Caring for Special Needs Child
Transporting Child
Ironing
Light Housekeeping
Travel
Transporting Professional
Cooking for Family
Cooking for Children
Managing Domestic Staff
Travel Planning
Party Planning
Other