Caregiver Canada - Caregiver Family/Employer Application

Canadian Caregivers’ Association (CCA) is a non-for-profit organization that was established to protect the rights of Canadian families and caregivers from all over Canada and warn them about malpractices in this business.

The CCA is proud member of Ontario Coalition for Better Childcare.

I AM A FAMILY/EMPLOYER

Employer Application
* Indicates required fields

Mother*:

Father*:

Occupation*:

Bus. Tel.:
Bus. Fax:

Bus. Tel.:
Bus. Fax 2:

Home Tel.*:

Home Fax:

Home
Address 1*:

Home Address 2:

City*:

Province*:

Postal Code*:

On Public Transit*:

Yes No

Employer's E-mail Address*:

Children:

1. Name: Age:
School:

2. Name: Age:
School:

3. Name: Age:
School:

4. Name: Age:
School:

5. Name: Age:
School:

Do you prefer
a non smoker*:

Yes No

Will you accept
a social smoker*:

Yes No

If they smoke in restricted area Other Preference

Age range preferred:

Childcare training*:

Experience*:

Swimmer*:

Yes No

Driver's license*:

Yes No

Accommodation*:

Duties*:

Change Diapers	Toilet Train	Prepare Breakfast
Prepare Lunch	Prepare Snacks	Prepare Dinner
Children's Laundry	Children's Beds	Clean Bedrooms
Children's Bathroom	Drive to School	Walk to School
Take to Activities	Assist with Homework
Special Childcare Needs*:	Yes No

Housekeeping*:

Very Light

Light

Moderate

Heavy

Most of it

Vacuuming:

Child Related Areas only

Throughout

Dusting:

Child Related Areas only

Throughout

Mopping Floors:

Kitchen

Main Bathroom

Halls

Other

Evening Meal:

Prepare

Assist

Meal Planning by Parents

Clean Up

Breakfast:

Family

Children Only

Lunch:

Family

Children Only

Laundry:

Family

Children Only

Ironing

Pet Care:

Dog(s)	Cat(s)	Other
Feed	Walk	Other

Household Appliances:

Oven / Stove	Microwave	Dishwasher	Trash Compactor
Washing Machine	Dryer	Vacuum Cleaner	Wall Vacuum

Work Schedule*:

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Hours*:

Shift work*:

Wages offered*:

Overtime anticipated*:

Other comments regarding the position:

How did you hear about our service?

MEMBERSHIP:

Forwarding by mail today

Pay Pal