Daycare Backup Application

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Home Phone:	Alt Phone:	Fax:

Best time to call:	Email:

Her Occupation:	Work Phone:

Place of Employment:

Cell Phone:	Email:

His Occupation:	Work Phone:

Place of Employment:

Cell Phone:	Email:

Emergency Contact (other than parents):

First Last

Phone

I am interested in Nanny Nexus Temps for (check all that apply):

Children:

Name:	Age:	Date of Birth:	Male or Female:

Press the "+" to add more

Do any of your children have special needs?

Yes
No

If yes, please explain:

If your children are in school what hours do they attend school?

Please list any pets in the house:

Do any other family members or friends live in your home (grandparents, aunts, uncles, etc.)?

Yes
No

If yes, please describe the situation:

Does anyone in your home smoke?

Yes
No

Does your temp need to drive?

Yes
No

If yes, will the Nexus Temp use:

Their Own Car
Client's Car

If client is providing a car:

Manual
Automatic

Can the Nexus Temp bring their own child?

Yes
No

Transportation Waiver: (optional)

I hereby give my consent for a Nanny Nexus Temps to transport my child(ren) in her or my automobile. I understand that Nanny Nexus Temps are not employees of Nanny Nexus and that Nanny Nexus is making no representation or warranties relative to the Caregiver's suitability to transport my child(ren). Nanny Nexus is in no way responsible for the safety of my child(ren) while being transported in Caregiver's or my family's automobile. I agree to indemnify, release and hold harmless Nanny Nexus, its agents, employees and officers for any and all claims including injury to Client's car or child(ren) while being transported by Nanny Nexus Temps.

I understand and agree to the above transportation waiver
I do NOT agree to the above transportation waiver

Medication Release: (optional)

I hereby give my consent for a Nanny Nexus Temp to administer medication to my child(ren). I understand that Nanny Nexus temps are not medically trained. I agree to indemnify, release and hold harmless Nanny Nexus, its agents, employees and officers for any and all claims relating to a Caregiver's administering of medication to my child(ren).

I understand and agree to the above Medication Release.
I do NOT agree to the above Medication Release.

Nanny Nexus Temporary Services Client Understanding and Release:

Understanding between parties:

1. Nanny Nexus agrees to make its best effort to locate temporary child caregivers for client's childcare needs on an as-requested basis.

2. Client agrees to pay caregivers directly for services rendered at $16.00 per hour.

3. Client understands that they need to pay the agency fee for every confirmed reservation.

4. Client understands that if s/he cancels a caregiver who has already been confirmed by Nanny Nexus s/he will be charged the agency reservation fee. Client further understands that if canceling with less than 24-hour notice, s/he will be charged the four-hour minimum for the caregiver in addition to the agency reservation fee. Cancellations must be made to Nanny Nexus 24-hours prior to service; or by 4:00 pm Friday for a Saturday, Sunday or Monday on all temporary jobs to avoid payment to the nanny/caregiver. A temporary placement greater than 6 days requires a one-week prior cancellation. Failure to cancel within the prescribed time frame will result in payment to the nanny/caregiver of:
--- 25% of potential earnings for temporary jobs 10 days or shorter.
--- One-week severance pay for temporary jobs over 10 days in length.
--- Up to $75 of the agency fee is non-refundable, if the client cancels

5. The fees are time and a half on holidays (New Year's Eve, Valentines Day, Memorial Day, Labor Day). If the child is driven mileage should be paid to Nexus temp. If the child is sick Nexus Temp is paid an additional 20%.

6. Client understands that the services provided by all caregivers referred by The Agency must be contracted through The Agency office. Client further understands that the use of an Agency caregiver, or referral of an Agency to a third party, without arranging the visit through the agency, is considered "theft of services" and will result in a charge of $2,500 for liquidated damages.

7. In the event that Client wishes to hire a nanny referred by Nanny Nexus on a permanent basis, placement fee will be required. Nanny Nexus standard placement fee for a permanent Caregiver ("Nanny") is $1,400 for a part-time/full-time nanny.

8. Client understands that caregivers working with Nanny Nexus are not employees of Nanny Nexus. Client understands that if they pay more than the allotted government amount per calendar year to any one caregiver s/he is responsible for withholding and filing employment taxes for that person. Social Security number of caregivers must be obtained directly from caregivers.

9. Client agrees to forever indemnify, release and hold harmless Nanny Nexus its agents, employees, and officers for any and all claims relating to services provided by caregivers.

By typing your name and submitting the form as completed above, you agree that you have read and agree with the information on this form. You also agree to comply with it, and agree to pay any applicable fees, listed above.

Full Name:

Date Application Completed:

Check the box below:*

I have read and understand the terms of agreement

Call Us at (913) 669-5355

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