spacer - child care and elderly care in Georgia
spacer - child care and elderly care in Georgia
CAREGIVER REQUEST FORM - Atlanta, Charlotte and Greenville

NOTES: This form is secured for credit card acceptance.
Your personal information will not be sold or distributed.
You may also call us for orders at 770-725-2748.

All requests for service placed after hours or when the office is
closed will be responded to the next day, Monday through Saturday. 
If you need service the same day or before 10 am when the office re-opens,
please call 770-725-2748 and choose Emergency Paging System.

Fields marked with an * are required.

*Are you currently a Member of A Friend of the Family?
Today's Date:    
*Name
*Home Phone
*Address
*City
*State
*Zip
*E-mail
*Area of Town
*Major Intersection near your home
Work Phone
Mobile Phone
Spouse's Name
Spouse's Work Phone
Spouse's Beeper/Car #
Spouse's E-mail
Fax #
How did you hear about A Friend of the Family?
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THE CARE IS FOR:
*Name
*Date of Birth
Name
Date of Birth
Name
Date of Birth
Name
Date of Birth
Describe Any Special Needs (i.e. physical disability, behavioral concerns, medication, allergies, etc.)
Does either parent work in the home? Yes No
Describe Pets In/Outside of Home
 
Please Give a Detailed Job Description
 
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*WHEN IS CARE NEEDED? - PLEASE CHOOSE ONE
1. Dates to be announced later

2. Specific date(s) and time(s):
DATE: - TIME: AM PM to AM PM
DATE: - TIME: AM PM to AM PM
DATE: - TIME: AM PM to AM PM
DATE: - TIME: AM PM to AM PM

Overnights? Yes No Travel involved? Yes No

3. Consistent Care: specific dates and times on a regular schedule for 1 month at a time from the start date and a minimum of 16 hours per week. The Non Refundable Premier Membership fee is $275 and gives you access to all of our services and all searches for Temporary Service, Consistent Care (1 month at a time) or Long Term Placement (1 year at a time). Members pay the Caregivers their hourly wages. Consistent Care clients pay the referral fee once the caregiver is hired. The Consistent Care referrals are due in advance for two months at a time.
Starting Date: Ending Date
Schedule (i.e. Monday 8AM-5PM) :
4. Long Term: full time or part time placement for a year at a time.
The Non Refundable Premier Membership fee is $275 and gives you access to all of our services and all searches for Temporary Service, Consistent Care (1 month at a time) or Long Term Placement (1 year at a time). Members pay the Caregivers their hourly wages. Long Term Placement fees are paid after a 30 days trial period and are based on a percentage of the Caregiver's annual salary or a set minimum, whichever is greater.
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CAREGIVER PROFILE: Please indicate preferences by marking the following questions
Live-In?
Yes No
Swimmer?
Yes No
Non-smoking Household?
Yes No    
Special skills
Need own car on job?
Yes No Will supply car on job? Yes No
Additional Caregiver profile:
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*
POLICIES
 

1. I understand that the initial Membership fee is $150 for temporary services or $275 for the Premier Membership and is non refundable.

2. I understand that the renewal fee will be charged to my credit card each year but I can cancel the service at any time after the first year. The renewal fees are $100 for temporary membership and $250 for Premier Renewals.

3. I understand that I will be charged a daily referral fee each day I request to have a caregiver.

4. I understand that the fee the agency charges is for the services of making a referral and not for the services of the caregiver.

5. I understand that if I cancel or change the date and/or time significantly of the request for a caregiver after the agency has made a referral, that the referral fee is due for each day of service that I have requested up to 10 days

6. I understand that I have the right of refusal any time a referral has been made. I also understand that if I cancel the request for service due to rejecting of a referred caregiver, I will agree to allow the agency the opportunity to refer another equally qualified caregiver. I understand that I will be charged for each day of service that I requested if I do not give the agency the opportunity to make additional referrals.

7. I understand that any time I use any services of an active or inactive caregiver that the agency has referred, the agency is due a daily referral fee at current market rates.

8. I understand that all requests for service should be made through the agency and not directly with the caregiver to ensure the best possible service.

9. I have read and agree to the current rate schedule.

*I HAVE READ, UNDERSTAND AND AGREE TO THE AGENCY POLICIES STATED ABOVE.
I Agree I Do Not Agree

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Billing Information

Our refund policy: We do not refund for completed order processing or completed referral services.
  Credit Card Type:
  Credit Card Number:
  Card Verification Value (CVV):
What is this?
  Exp. date:
  Name on Credit Card as it appears:
  I prefer not to give my billing information online. You may call me for this information.
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Enter Security Code:

Your privacy and security is important to us. Please review our privacy policy.

       

If you do not receive an email confirmation of this request,
please call us at 770-725-2748.


Friend of the Family is an equal opportunity referral service. We refer without regard to age, sex, religion or national origin. We do recognize the right of each family to hire the Caregiver of its choice.
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GA, NC and SC (I-85 corridor) & Montgomery, AL
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spacer - child care and elderly care in Georgia
spacer - child care and elderly care in Georgia

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