EMC Caregivers Canada - Family Application

* These are required fields.

Parent's Information:

First Name*:

Last Name*:

Middle Initial:

Address*:

City*:

Province*:

Postal Code*:

Home Phone*:

Work Phone:

Fax Number:

Cell Phone:

Email Address*:

Preferred contact method*:

Best time to contact you*:

Children Information:

Please specify information about your child(ren). (List number of children and ages.)*:

Are you expecting?:

Is the care required due to a disability or medical condition?:

Elder Care Information:

Please specify information about elder(s) in your home:*:

Household Information:

You have pets in the house?:

Area Home is Located*:

Number of bedrooms in home:

Number of bathrooms in Home:

Position Requirements:

Starting Date:

Do you require that the Caregiver has a valid Driver's License?:

Special skills required (eg. swimming)?:

Duties and Responsibilities:

In addition to childcare, the caregiver will be expected to (Check all that apply):

Other:

Accommodation Details:

The caregiver will have (Check all that apply):

Other:

Meeting Availability:

Please indicate your preference for interview meeting times (Check all that apply):

Additional Questions:

Please, specify the need for a Caregiver to live in your home on a full time basis:

What specific efforts have been made to recruit a caregiver up to now?:

How did you hear about our placement agency?:

Please, share any comments that you think would be helpful to us:

for families

for caregivers

For Families

Family Application Form

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