Fill In Form

Starting August 17, 2010 we are restructuring our placement process to better serve the needs of our current clients. We apologize for not answering in time to you submitting the profile.

Fields marked with * are mandatory.

General Information	Host Father	Host Mother
First Name: *
Last Name: *
Occupation:
Start/End of Work Hours weekly:	to	to
Travel Time To/From:
Business Name:
Business Address:
Work Phone Number:	- -	- -
Work Fax Number:
Work E-mail Address:
Home Address: *
City: *
Province: *
Postal Code: *
Home Phone Number: *	- -	- -
Home Fax Number:
Home E-mail Address: *
Marital Status:	Single     Separated Married   Divorced	Single     Separated Married   Divorced
Please list Resident Status:
Spoken Language(s):

General Information	Children
Name:
Birth Date: (Year *)	1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Sex:	Male Female	Male Female	Male Female
Special Interests:
Hours/week attending school:

Arrival Information for the Caregiver
Preferred Starting Date: *	2008 2009 2010 2011 2012 2013 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Preferred Arrival Airport (if applicable)

Housekeeping Information
Do you have a housekeeper, cleaning service or yard maintenance? *	Yes     No
How often?	Hours   Per Week   Per Month
Do you expect this to change with the arrival of your Caregiver? *	Yes     No
Please describe the housekeeping/kitchen and other duties beside childcare:
How important is it to have your home clean and tidy? Please describe:
Type of Home: *
Apartment:	Low Rise     High Rise     Condominium
House:	Town House     Duplex     Detached House
Number of Rooms:       Number of Floors:       Household Members:

Accommodation & Privileges for the Caregiver:
Please check all that apply: *
Private bedroom	Separate level from family	Separate quarters
Private bathroom	Shared bathroom	With whom:
Other:
Own car	Childcare-related use only	Limited personal use
Unlimited personal use	Please explain:
Access to telephone?	Yes   No       Restrictions:
Access to television?	Yes   No       Restrictions:
Friends over?	Yes   No       Restrictions:
Other privileges:

Family / Home Neighborhood
Please state location of employment:	Metropolitan   Urban   Rural
Is your family in good health?	Yes   No   Please Explain:
Religious affiliation(s):	Protestant   Catholic   Jewish
	Other:
Are there frequent overnight guests?	Yes   No
Is there any smoking in your home? *	Yes   No
Are there any pets? *	Yes   No   Please describe:
Have there been any incidents of domestic violence in your family that were reported to the police or social service agencies? *
	Yes   No   Please explain:
Has anyone in your home ever been convicted of any offense other than a minor traffic violation? *
	Yes   No   Please explain:
How close are you to churches, shopping centers, entertainment, etc.?
Describe any other similar experiences your family has had:

Qualifications of the Caregiver
Does your Caregiver need to be: *	Female     Male     Either
Does your Caregiver need to be able to: *	Drive     Swim     Cook
Can the Caregiver be of another religion?	Yes     No
What nationality(ies) do you prefer?
What languages do you prefer?
Please specify the nature of the live-in care required:
Please outline any specific qualifications your prospective Caregiver must posses:
List other qualifications / restrictions (distinguish between what you require and what you prefer):
What do you feel are the most important characteristics of a successful Caregiver / Host Family relationship?

Working Hours and Wages Hours to work per day:
Sunday	From:   To:
Monday	From:   To:
Tuesday	From:   To:
Wednesday	From:   To:
Thursday	From:   To:
Friday	From:   To:
Saturday	From:   To:
Total hours of work required per week: *
Is the Caregiver required to work irregular hours / shifts? *	Yes   No   Please explain:
Days Off: *
Paid Vacation (No of Weeks):
Gross Wage:	$ per   Hour   Week   Month

Leisure Time
How do you spend your leisure time and what major interests do you have that may affect your Caregiver requirements?
Please select the activities that describe your family’s interests or hobbies:
cooking   reading   museums   drama   hockey   dining out   artwork   music   piano   skiing   sports – general   photography   cycling   skating   swimming   hiking   golf   dance   boating   travel   community service   horseback riding   gardening   fishing   socializing   other
Do you have any vacation plans for the next year to which your Caregiver will be invited?

Prior Experience with Caregivers
Have you ever had live-in help before? *	Yes     No
If yes, was your experience a good one? *	Yes     No     Please explain:
Name of prior Caregiver or Nanny:
Agency used, if any:
Length of Stay:	to	Reason for leaving:

How did you hear about Elite Care - International Migration Facilitators Inc.

Please select: *

Search Engine     Yellow Pages     Poster     Flyer/Literature

Referral     Referred by:

Other     Please specify:

References (non-relatives)	Name	Phone Number	Relationship to You