Thank you for your interest in Eden Brook Care. There is a non refundable application deposit fee of $250.00 to register with us. Correspondence with your prospective Caregivers would be forwarded through Eden Brook Care until both parties agreed to disclosure of personal contact information.

Only non-identifying information will be released to the Caregivers. Once you select one of our Caregivers, you will be required to pay our organization an agency fee of $750.00 when the candidate selected accepts your offer of employment. We trust that you will give us the opportunity to work with you in finding a suitable candidate to satisfy your needs.

Please fill out all applicable fields in the form below, and send by clicking on the "Submit" button when completed {or you can print this page and fax it back to (647) 439.1548}.

Contact Information

Full Name:

Surname (Last name)
First name (Given name)
Middle initial(s)

Spouse's Name:

Surname (Last name)
First name (Given name)
Middle initial(s)

Home Address:

No. Street Apt./Suite No.
City
Province
Postal Code

Home Location:

City
Suburb
Country district

Telephone No:

Home: (with area code)
Your Business: (with area code)
extension:
Spouse's Business: (with area code)
extension:

e.mail Address:

Type of Care Required

What type of Caregivers are you seeking?

Who is this care for?

Age of person needing care:

Gender:
Male Female

When do you require the Caregivers to commence working?

If care is required for your child(ren)

How many do you have?
How old are they?
Boys Ages: years old
Boys less than one year of age: months old

Girls Ages : years old
Girls less than one year of age: months old

What are the required hours of work?
am pm to am pm
Total hours per week:

Proposed Wages:

What are the required working days per week?
Sun Mon Tue Wed Thu Fri Sat

What is most important to you?

Atmosphere/Comfort Level
Equipment & Amenities
Financial Considerations

Safety Provisions
Services & Activities
Staff

Other:

How long do you need this care?
6 months 1 year Long-Term

Family Schedule

Do you work on a shift basis? Yes No
If "yes", please provide details regarding your work hours for each work day:

What are your days off from work?
How many days off from work do you have each month?

What are your family's interests and activities, apart from work?

Special Needs

Does this person/child(ren) have special needs?

Yes No
If "yes", please provide details:

Have you had a live-in Caregivers before? Yes No
If "yes", what is his/her current status?

Please indicate by checking the applicable boxes at right the duties that your Caregivers will be required to perform regarding your child(ren):

Prepare their meals
Feed them
Bathe and dress them
Read with them
Play with them
Do crafts with them
Teach them numbers and alphabet
Do laundry
Clean bedroom(s)
Clean playroom(s)
Clean bathroom(s)

Are there any other duties that your Caregivers will be required to perform regarding your child(ren)? Yes No
If "yes", please list them:

Do any of them attend preschool or nursery school? Yes No
If "yes", please provide details:

Will your Caregivers be required to perform any duties for the rest of the household? Yes No

If "yes", indicate which at right:

Cook
Do dishes
Dust
Make beds
Do laundry
Iron
Vacuum

Your Caregivers

Will your Caregivers have separate accommodation from the rest of the family, e.g. basement apartment or separate section of the house? Yes No
If "yes", please describe briefly:

Will your Caregivers have a private bathroom? Yes No
If "no", with whom will s/he share a bathroom?

Must your Caregivers be a licenced driver? Yes No
Will s/he be required to drive this person/child(ren) anywhere, e.g. to and/or from school, to and/or from activities outside your home, etc? Yes No If "yes", please provide details:

Will your Caregivers have access to a vehicle owned by you or a family member for her personal use?
Yes No

Must your Caregivers be a non-smoker? Yes No Doesn't matter
Do you or any member(s) of your household smoke? Yes No

Is there a swimming pool at your home? Yes No
Must your Caregivers be able to swim? Yes No
If yes, to what degree? Very well Moderately well Not much

Do you have pets? Yes No
If yes, what kind? Dogs Cats Birds Other:

Will your Caregivers be required to look after your pet(s)?

Yes No

Other Information

Is there any information that we have not requested but which you think we should know?

Ask Questions
You have the opportunity to ask questions, related to your request, that we will answer in our response.

Question #1:
Question #2:
Question #3:

Method of Payment

We offer several Easy and Convenient ways to pay your application fee. Please note: Applications will not be processed without payment.

Secure order processing through PayPal: Click here This is a premier secure credit card transaction service. We accept the following credit cards.

Faxed Credit Card form: Click here for copy of printable credit card slip. Fax: (647) 439-1548

Pay by Mail - using personal checks, money orders, cashiers checks or company checks.

Mail:

Eden Brook Care

545-3364 Keele Street,

Toronto, Ontario

M3J 1L5, Canada

Please select method of Payment

Legal Waiver

I fully understand and agree to the terms and conditions of the services offered by Eden Brook Care. I agree to submit the following documents to Eden Brook Care which will be kept in the strictest of confidence when requested:

1. Copies of proof of residency for the person to be cared for must be provided and may include: Birth Certificate, Proof of Citizenship, Passport, or where applicable, Drivers license, copy of tax bill with care recipient's name and address, or pension stub.

2. Social Security Number or Social Insurance Number for Canadian & U.S. clients.

It is understood and accepted that Eden Brook Care will perform a background check on all employers and their spouse when a match is found.

I agree to the fees, guarantee, refund and confidentiality policies.

I fully understand that only non identifying information will be used to search for a Caregivers. When a match is successful and both parties agree Eden Brook Care will be permitted to disclose to the selected Caregivers the contact information. All communications prior to selection will be through Eden Brook Care.

I agree to pay all fees in Canadian funds.

I accept the terms and conditions stated above by submitting this application to Eden Brook Care Consulting Service.

© 2002 Eden Brook Care.