Bay Area 2nd Mom, Inc. - Client Interest Form



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Client Interest Form

Please note: Red asterix ( * ) indicates a required field. This is unified form for Child/Senior Care, please fill the corresponding fields to your interest only. Thank you.

CONTACT INFORMATION

* Name:

* Address: (line 1)

* Day Phone:

Evening Phone:

Address: (line 2)

Cell Phone:

Fax:

* City:

* State:

* Zip:

* E-mail: (correct email format required)

How did you hear about us?

SINGLE FAMILY / INDIVIDUAL

Type of service you are seeking

Child Care Senior Care

House Manager Personal Assistant

Housecleaner

Date(s) and Hours for Care

Are there any smokers? Yes No
Is there a pool? Yes No
Do you have any pets? Yes No

Schedule required (Check all that apply)
Long Term (3+ mo)
Temporary (1 wk to 3 mo)
On-Call (as needed)

Live-In		Part Time
Live-Out		Full Time

Number of children

Please list the ages of your children

Considerable Salary Range

HOTEL GUEST

Name of your Hotel

Hotel Phone

Hotel City

Arrival Date

EVENT GROUP CARE

Name of Business or Group

Type of Event

Event Address

Event Contact Phone

ADDITIONAL COMMENTS AND NOTES

This form is intended to provide basic information so we can better assist you. Submitting this form does not confirm, guarantee, or schedule services through Bay Area 2nd Mom, Inc.


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