Nanny Brokers USA- Temp Services Agreement
(334) 208-9877
Temp Service Membership Agreement
Upon receiving this completed agreement & Application fee, we will immediately begin to process your order.
We will call you to confirm your order. Once registered , you can then call an use our Temp service's at anytime
you need to book a sitter.
Please refer to the CURRENT rate sheet on our website www.nannybrokers.com
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 Care ____________ / ___________ / _____________
________ / _________ / ____________/ ____________/ _________/ ___________ / _______
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_______
Anything the Caregiver should know?____________________________________________
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 the agency cannot guarantee the Caregiver can stay longer than booked, if you have not reserved those hours
before hand.
___I understand there will be a $29.95 cancellation fee if you need to cancel reservation within 24 hours of the booking.
___I understand that for last min. 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 booking fee charged does NOT pay for the sitter/caregivers salary.
___I understand that the Sitters are NOT employees of the agency but independent contractors.
___I understand that Holiday Rates 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 Only CASH PAYMENTS are to be made to sitter at the end of each day .
___I understand that the caregiver May NOT transport my child without a signed consent form issued by the agency, and
signed by all parties involved..
___Nanny Brokers USA is in no way responsible for the safety of my child(ren) or Family member while being transported in
caregivers or family's automobile.
___I understand and agree that Nanny Brokers USA and/or any or their acting Agents is NOT responsible for any injury, loss,
death, or personal damages, that may result in the actions or omissions from any of our staff or caregivers.
___I agree to indemnify, release and hold harmless Nanny Brokers USA its agents, employees and officers from any and all
claims, including injury while being cared for or transported by a Nanny Brokers USA caregiver.
*I HAVE READ, UNDERSTAND AND AGREE TO THE AGENCY POLICIES STATED ABOVE.
I Agree____ (Please Initial)
Client Name___________________________________________________________________
Address__________________________________________City_______________State______ Zip_________
Home Phone _______________________ Moms cell_____________________Dads cell____________________
Fax_________________________
Children Info
Name___________________age______ any concerns________________________
Name___________________age______any concerns_________________________
Name___________________age______any concerns_________________________
Name___________________age______any concerns_________________________
Parents signature____________________________________________________Date_____
I HAVE READ , UNDERSTAND AND AGREE TO THE AGENCY POLICIES STATED ABOVE.
Family Signature_______________________________________________________Date________________________
Office use only
Acct #__________________Application received_______________ expires___________
Paid $_______ Check __________ Money Oder______Credit Card _______________________Exp__________
OFFICE use
Caregiver 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____
(334) 208-9877
email admin@nannybrokers.com
Notes to the Parents:
When the Caregiver Arrives
Ask the Caregiver to arrive at least 15 minutes before you depart. Make sure that you let the nanny know
exactly where you will be and how you can be reached. Write down the address and telephone number of
where you will be. Also make a list of emergency telephone numbers: a friend or relative, the children's
doctor, the police department, the fire department, an ambulance service, and the poison control center.
Carefully go over any family rules and daily routines, paying special attention to eating or sleeping
arrangements. Take the nanny on a tour of the house, showing her any first aid equipment and all doors and
possible exits. It is a good idea to discuss the family rules regarding television, snacks, and bedtime with
both the Nanny and the children present. It is the parents' responsibility to let the children know what rules
are to be obeyed when the parents are out of the house