Guaranteed Babysitting Service Registration |

Date Registered
Type of Service Needed
Guaranteed Babysitting
Parent 1 Full Name *
Parent 1 Cell Phone *
Parent 1 Email *
Parent 2 Full Name *
Parent 2 Cell Phone *
Parent 2 Email *
Home Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Home Phone
Work Phone
Number of Children in the Household
Child 1
Gender
FemaleMale
Birth Date
Child 2
Gender
FemaleMale
Birth Date
Child 3
Gender
FemaleMale
Birth Date
Child 4
Gender
FemaleMale
Birth Date
Do any of your children have food allergies?
If yes, please explain below.
Do any of your children have any special needs such as: health, behavior, emotional, or academic concerns?
If yes, please explain below.
Please describe each child's personality and development stage.
Please briefly describe any family activities and interests.
Please briefly describe the type of parent you are.
Ex: Lenient, structured, etc...
Do you have any pets?
If yes, please explain below.
Special Observances
Ex: Diet, holidays, religious celebrations, etc...
How would you describe your home lifestyle?
Does anyone in your home smoke?
How did you hear about Preferred ChildCare, Inc.?

336-392-7827