Domestic Care Companions Application Please fill out this form and click "Send". Step 1 of 4 25% Name* Are you the:* Client Relative Other If other, please explain: Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Alternate PhoneBest time to call:* Email* Emergency Contact Name Prefix First Last Suffix Emergency Contact Phone Compassionate CompanionPlease complete this section if you are requesting a Compassionate Companion for the elderly, non-medical care, or short-term disability.Name First Last AgeDate of Birth Month Day Year Name First Last Age Date of Birth Month Day Year Do any of these individual(s) have any special needs? Yes No If yes, please explain: Pet CarePlease complete this section if you are requesting pet care services.Pet #1 - Name Pet #1 - Kind of Pet (include breed if known) Pet #1 - Age Pet #1 - Male or Female Male Female Pet #2 - Name Pet #2 - Kind of Pet (include breed if known) Pet #2 - Age Pet #2 - Male or Female Male Female Pet #3 - Name Pet #3 - Kind of Pet (include breed if known) Pet #3 - Age Pet #3 - Male or Female Male Female Do any of your pet(s) have any special needs? Yes No If yes, please explain: Below applies to all services requested.Start Date Requested MM slash DD slash YYYY Required Hours and Days: What skills and abilities would you like to have in your employee?Will your employee need to supply a car? Yes or Will you supply a car? Please note:If you are not supplying a car and will need transportation, you are responsible for reimbursing your caregiver mileage at the current government allotted rate.Is the care a Manual or Automatic? Manual Automatic Would you allow your caregiver to take you or your elderly on outings? Yes No If yes, what kind of outings would you like your caregiver to provide?Do you require the caregiver to cook for: Elderly Family All/both None of the Above Do you require the caregiver to do laundry? Yes No Do you require the caregiver to do light housekeeping? Yes No Do you require the caregiver to do your grocery shopping? Yes No Do you require the caregiver to do your personal shopping? Yes No What other kinds of errands would you like your caregiver to do?Example - Pick up/drop off from activities, pick up prescriptions, take pet to vet, drop of dry cleaning, etc)Do you have any other comments at this time that you feel you should add?How did you hear about Nanny Nexus? Nanny Nexus Services Client Understanding and ReleaseUnderstanding between parties: 1. Client agrees to pay caregivers directly for services rendered at least. 2. 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 $2500 for liquidated damages. 3. In the event that Client wishes to hire a nanny referred by Nanny Nexus on a permanent basis client agrees to pay Nanny Nexus placement fee for a permanent Caregiver is $1,400. 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 anyone 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. 4. 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:* First Last Date Application Completed:* Month Day Year * I agree that all of the information on this application is true to the best of my knowledge.