Child Care Information- Please use

Number of Children:
Name: Age:
Name: Age:
Name: Age:
Name: Age:


Special Activities

Breakfast is to be prepared at
Lunch is to be prepared at
Dinner is to be prepared at
Home work is to be done at
Bed time for the Children

Medical Information
Have your children had any medical injuries in the past twelve months ? Yes No
Does your child suffer from any illness Yes No if yes what illness
Does the child take any special medication Yes No if yes what medication does the child take
Does your child have any known allergies to medications, food pets or any other substance if yes please list here

Emergency Information:
Name: Phone # Relationship to the Children
Name: Phone # Relationship to the Children
Name: Phone # Relationship to the Children


Name of the Family doctor phone #

Parents Contact Information
Name

Work # ext
Cell phone #
Other

Specific Information

Are your children involved in any extra curricular activities
Are your children prohibited from viewing any particular television programs

Do your children need special permission to have friends over at the house.

Any other chores that might need to be done

By clicking the submit button I authorize Princess Home Solutions to charge the first weeks salary of the contractor as a placement fee. I also agree to pay Princess Home Solutions for the services I have requested.