Hire a Special Needs Caregiver

Call Now 780 430 7987

 Mr. Ms. Mrs. Dr. Prof.

First Name:

Last Name:


Home Street Address:

Home City:

Home State/Province:

Home Country:

Home Postal Code:

Mailing address, if different from home:

Phone Number:

Mobile Phone Number:

Fax Number:

Date of Birth:

 E-mail Opt Out

 Fax Opt Out

 Do Not Call

List name(s) and date(s) of birth of those requiring care:

Who is currently responsible for their care?

Concerns, diets, allergies, disabilities:

Have you previously hired a caregiver?
 Yes No

Additional information on your lifestyle, etc.

Nanny duties/criteria:

Languages spoken at home (English, French, etc.):

Medical Information:

Other persons living in home:

Please describe any pets in the home:

Revenue Canada Business Number:

Type of Accommodation Provided:

When is help required?

Who did you find helpful at Preferred Personnel?

How did you hear about Preferred Personnel?

Work Day Start Time:

Work Day End Time:

1 + 1 = ?