Child Care Related Service Request Form Child Care Related Service Request Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country PhoneMobile Phone*Email* Child Service Request* Nanny (live-in) Nanny (commuter) Newborn Care After-School Childcare For newborn service only - Do you require a Licensed Practical Nurse or a Pediatric Nurse for the assignment? Yes No Childcare Schedule* Part - Time Full - Time Evening Weekend only Summer only Other __________________________________ Special Occasion ______________________________ Other or Special OccasionWeekdays you need the service Monday Tuesday Wednesday Thursday Friday Monday - Specify HoursFor example, from 2PM to 5PM. Tuesday - Specify HoursFor example, from 2PM to 5PM. Wednesday - Specify HoursFor example, from 2PM to 5PM. Thursday - Specify HoursFor example, from 2PM to 5PM. Friday - Specify HoursFor example, from 2PM to 5PM. Specify if you need weekend services Saturday Sunday Saturday - Specify HoursFor example, from 2PM to 5PM. Sunday - Specify HoursFor example, from 2PM to 5PM. Car Requirement: Care Specialist will use own and will receive milage reimbursement Car will be provided by the family for the errands and other work related duties Projected hire time:*Please be as specific as possible in order to determine the time frame to complete your placement process. Thanks.Benefits: indicate which of the folowing you will provide. paid vacation paid Holidays Paid sick days Share the health insurance cost Bonus Other _______________________________________ Keep in mind the Illinois fair employment requirements. Visit their link at http://www.illinois.gov. You can also consult with GTM Associates by calling 888-432-7972 NOTE: Full-Tme and Part-Time employees appreciate any benefits you can add to their salaries. You may decide to provide a bonus for special occasions as a way to nurture long-term services. You can call us for a consultation regarding benefits. You can contact us via our "contact us" form or by calling 312-918-6741.Other Share this:Click to share on Facebook (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to share on Twitter (Opens in new window)Click to email this to a friend (Opens in new window)
