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Domestic Care Companions Application

Please fill out this form and click "Send".

Step 1 of 4

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  • Compassionate Companion

    Please complete this section if you are requesting a Compassionate Companion for the elderly, non-medical care, or short-term disability.
  • Pet Care

    Please complete this section if you are requesting pet care services.
  • Below applies to all services requested.

  • MM slash DD slash YYYY
    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.
  • Example - Pick up/drop off from activities, pick up prescriptions, take pet to vet, drop of dry cleaning, etc)
  • Nanny Nexus Services Client Understanding and Release

    Understanding 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.

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Telephone: 913-669-5355

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