Location of event/hotel (indoor/outdoor): (please give simplified directions & address)




Will an event/parking/permit pass be needed?

Parent Application

Parents Name:

Parents Address:

Closest Freeway off ramp:

Parents Phone Number:
HOME:
WORK:
CELL:

Email Address:
(Do you check daily/weekly?):

Childrens Names/ages:



Children's Allergies:

Special Needs of Children:

Do you have any pets? Please list them:
(I am allergic to cats).
When do you usually need a sitter? Day/evening/weekend/holidays?:

I am not available for regular nanny work at this time. Please see my referral area for additional information. In the future, I will be looking for this type of work.

Did you review my rates & services page?

How did you find my service/web site?:

Any other comments:

CONTRACT

Jessica Welch provides in-home child care & child care in individual family homes & event child care for children ages 0-14. Jessica Welch DOES have professional liability & premise insurance. You are, however, placing your child(ren) in her care at your own risk and expense. Please initial next to each numbered statement.

__1. California state law requires that all part-time and full-time nannies, baby sitters are registered with Trustline. This registration includes a local, state, and the federal criminal and child abuse background check and fingerprint scans. The client understands that Jessica Welch has her fingerprinting done through Community Care Licensing & The Department of Justice, and has completed the transfer process with TrustLine.

__2a. Client understands that Jessica Welch is CPR & 1st Aid certified for infants, children, and adults.
__2b. Client understands that Jessica Welch has a 100% clean driving record with the DMV of California. She has no tickets or accidents on her record.
__2c. Client understands that Jessica Weiner lives a smoke, drug and alcohol free life-style.

__3. Client understands if Jessica Welch will be providing regular child care for your child(ren), she requests that she and the client enter a separate written work offer agreement outlining the job description, schedule, duties, and her responsibilities along with the rate of pay, benefits, and vacation schedule the Client will be providing. This separate written work offer agreement is to be created , completed and signed by Jessica Welch and the client.

__4. Client agrees that he/she/it must determine whether any Jessica Welch is considered an independent contractor or an employee under California and/or Federal law. Client agrees that the work offer agreement is a strong indicator that the Contractor is actually an employee of the client. If the relationship between the Contractor and the Client is that of a domestic employee working for the employer, as defined under California employment law, then all local, state, and federal government requirements, including but not limited to, income taxes, social security (FICA), unemployment insurance, worker’s compensation, etc. shall be the Client’s responsibility.

__5. The parties to this contract agree that any dispute arising from this contract shall be settled by binding arbitration. California law shall apply and the matter shall be heard in San Diego, California. The matter shall be heard and decided by one (1) arbitrator mutually selected and agreed upon by the parties. The award rendered by the arbitrator shall be final and binding. The arbitration award can be confirmed in any court having competent jurisdiction.

__6a. Client agrees to pay Jessica Welch for hours worked for an on-call baby/pet/ house sitter or tutor. These hours worked can be purchased online through paypal.com or checks and cash may be accepted in person after job has been completed.

__6b. Client agrees to pay Jessica Welch a driving fee of .30 cents a mile from her home in Encinitas to your home.

__7. If the child(ren) is/are supervised in the home of Jessica Welch, the Client understands that there are 2 small Jack Russell Terriers in the home. Client releases Jessica Welch from liability for injury in and around the home because of the dogs’ activities or the dogs’ actions toward the children. Client understands that the dogs have never bitten anyone, or any animal, but accidents can happen, and the client understands and assumes responsibility of their child(ren) for anything that happens to him/her/them while in Jessica Welch’s care.

__8. Client understands that if any injuries occur to the child(ren) in the home because of horseplay or accident, that Jessica Welch is not responsible for paying doctor bills, hospital bills or emergency medical care. Client understands that whatever may or may not be covered under her renter's insurance, is the sole responsibility of the client.

__9. Client shall indemnify Jessica Welch as harmless from and against and pay on behalf of or reimburse such indemnified parties in respect of any loss, liability, demand, claim, action, cause of action, cost, damage, deficiency, fine or expense, whether arising out of third party claims (including, without limitation, interest, penalties, reasonable attorney’s fees and expenses, court costs and all amounts paid in investigation, defense or settlement of any of the foregoing deficiency, damage, or expense which Jessica Welch or any such indemnified parties may suffer, sustain of, become subject to, because of, in connection with, relating to or incidental to or by virtue of Client’s hiring of Jessica Welch.

__10. Client shall complete Emergency Medical Release form below:

Name/DOB of Children:

( ___/___/___ )DOB

( ___/___/___ )DOB

( ___/___/___ )DOB

Parent’s Name:

Parent’s Contact information:

Children’s Doctor:

Doctor’s Telephone Number:

Allergies to Medications:

Comments or Concerns:

I _______________________________________ give permission for all the above named children to be taken to the above named doctor in case of a non-emergency by Jessica Welch.

For an emergency I give permission for Jessica Welch to call 911 for an ambulance or to take any of the above named children to the hospital where they can administer the appropriate care.

I __________________________ give permission for all of the above named children to ride in Jessica Welch’s 2002 Subaru Forester, fully insured by USAA Company (Policy info: 00570 03 34C 7102 5 Contact: (800-531-8111) during the hours she is providing child care to my children. No child(ren) will be allowed in the front seat where there is an airbag & parents must show me how to use child safety seats.