Contact & Household

First Name

Last Name

Preferred Name

Email Address

Phone Number

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City / Neighborhood

ZIP Code

Number of Children

Children's Ages

About Your Children

Ages and stages needing care (check all that apply)

Infant (0–12 months)

Toddler (1–3 yrs)

Preschool (3–5 yrs)

School age (5–10 yrs)

Preteen (10–13 yrs)

Mixed ages

Specific needs? (check all that apply)

No specific needs

Food allergies or dietary needs

Learning differences

Developmental differences

Medical needs

Physical or mobility needs

Describe your children: personalities, routines, anything a caregiver should know

Schedule & Hours

Type of care needed (check all that apply)

Full-time (40+ hrs/week)

Part-time (15–30 hrs/week)

After-school only

Mornings only

Date nights / evenings

Overnight care

Weekend support

Flexible / as needed

Days needed

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Flexible

Usual start time

Usual end time

How soon do you need coverage?

Immediately — this week

Within 2–3 weeks

Within the next month

Planning ahead — 1–2 months

What You're Looking For

What matters most in a caregiver? (check all that apply)

Experience with young children

First aid / CPR certified

Formal childcare training

Non-smoker

Homework help ability

Consistent routines

Comfortable with pets

Bilingual caregiver

Do you need the caregiver to drive your children?

Yes — driving is part of the role

No — driving is not needed

Occasional driving only is fine

Open to it — depends on the caregiver

Language preference?

Any specific experience required?

Pets in your home?

No pets

Dog(s)

Cat(s)

Other pets

Allergies to animals

Describe your ideal caregiver

Compensation & Payment

Hourly rate you're comfortable with

$18–$22 / hr

$22–$26 / hr

$26–$30 / hr

$30+ / hr

Open to discussion

Preferred payment method

W2 / Formal payroll

Cash

Zelle / Venmo

Open to discussing

Your Home & Household

Household rules important for a caregiver to know (check all that apply)

Screen-free time

Specific dietary or allergy rules

Religious observance

No visitors during care hours

Pets with specific handling instructions

Other

Anything else about your home a caregiver should know before starting

Anything Else

Anything you'd like to add: the more we share, the better the match

Signature & Agreement

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Signature (enter your full legal name)

Date

Child Care Support Interest Form

Contact & Household

About Your Children

Schedule & Hours

What You're Looking For

Compensation & Payment

Your Home & Household

Anything Else

Signature & Agreement

Ready for steady support?

If It’s Not a Fit, You’re Not Stuck

+1(773) 600-8010

For Helpers

For Families

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Child Care Support Interest Form

Contact & Household

About Your Children

Schedule & Hours

What You're Looking For

Compensation & Payment

Your Home & Household

Anything Else

Signature & Agreement

Ready for steady support?

If It’s Not a Fit, You’re Not Stuck

+1(773) 600-8010

For Helpers

For Families