Nanny Brokers USA
Holiday Sitter Service Agreement
Upon receiving this completed agreement , we will immediately begin to process your order.
We will call you to confirm your order. Please fax this to 678 380-7158 AFTER 6 PM M-F
Please complete this Agreement :
(Please Print or Email us this completed form, then call our office to fax in this form BEFORE you use the service)
Date______ Home Phone #_______________________
Cell _________________________
Work_____________________________
Name______________________________________________
Address____________________________________________
City, __________________State____ Zip______________________
How did you hear about us?________________________________________
Dates & times you are requesting a Sitter ____________ / ___________ / _____________
________ / _________ / ____________/ ____________/ _________/ ___________ / _______
Names an ages of people seeking care :
1. ________________________________Date Of Birth ________Age_______
2._______________________ _________Date Of Birth ________ Age_______
3.________________________ ________Date Of Birth ________ Age_______
4._________________________________Date Of Birth ________ Age_______
5. _____________________ ___________Date Of Birth ________ Age_______
Any special needs?__________________________________
(medical problems, allergies, behavior concerns, medication,etc?)____________________________
Pets In the home?_______________
If Yes type Pet_______________
Job duties:_________________________________________________________
Please read and Initial _____
I understand that the agency must hold a valid Visa/ MasterCard/ AMEX # to confirm my reservation
I understand that there is a $10 additional charge if there is a time change in your reservation once the sitter is booked by the
agency.
I understand the agency can not guarantee the sitter can stay longer if you have not reserved those hours before hand.
I understand there will be a $39 processing fee if you need to cancel babysitting reservation within 13 days of the booking.
I understand that for same day cancellations, I am financially responsible for the hours I have reserved the caregiver as well as the
agency booking fee.
I understand that the daily agency fee charged does NOT pay for the sitters salary.
I understand that the Sitters are not employees of the agency but independent contractors.
I understand that Holiday Rates ( Such as Xmas Day or major Holidays) are paid at the same rate as overtime which is 1-1/2 times
reg salary hourly charged
I understand that all additional request for service MUST be booked directly with the agency and NOT the caregiver or my
membership will be canceled and I will be subject to breach of contract.
I understand that each day I use a caregiver the agency charges me an additional daily fee.
I understand I am not to refer the Caregivers to any friends or family members or I will be responsible to pay for all appropriate
referral fees just as if I used the caregivers myself.
I understand that the sitter May NOT transport my child without a signed consent form issued by the agency, and signed by all parties
involved..
I understand that Only CASH PAYMENTS are to be made to sitter at the end of the assignment .
I HAVE READ , UNDERSTAND AND AGREE TO THE AGENCY POLICIES STATED ABOVE.
Family Signature_______________________________________________________Date________________________
Office use only
Application received_______________ expires___________
Paid $_______ Check __________ Money Oder______
Credit Card # ___________________ _______________________Exp__________ 3 digit sec code_______
OFFICE use
Sitters Booked
1 _________________________________________date_______ Fee____
2_________________________________________date_______ Fee____
3 _________________________________________date_______ Fee____
4 _________________________________________date_______ Fee____
5__________________________________________date_______Fee____
6__________________________________________date_______Fee____
7__________________________________________date_______Fee____
8__________________________________________date_______Fee____
9__________________________________________date_______Fee____
10_________________________________________date_______Fee____
Nanny Brokers USA PO. Box 131 Lilburn , Ga. 30047 (678 )380-7158
email admin@nannybrokers.com
$50.00 Registration Fee