Gatehouse Registration Form

General Family Info
Preferred Family Name*

i.e. "The Jones Family" or "The Jones-Smith Family"
Parent/Guardian First Name*
Parent/Guardian Last Name*
Email*

This is the email our agency will be using for all correspondence.
Best Contact Number:*
Children
This information will be used to create a Family Care Guide that will be shared with the nannies scheduled with your family.
Child 1 Name:*
First Last
Sex:*
- Male
- Female
DOB*
MM slash DD slash YYYY
School Name and Address
Please list any allergies, medical conditions or special needs.*
Please list your child's activities, interests and hobbies.*
Child 2 Name:
First Last
Sex:
- Male
- Female
DOB
MM slash DD slash YYYY
School Name and Address
Please list any allergies, medical conditions or special needs.
Please list your child's activities, interests and hobbies.
Child 3 Name:
First Last
Sex:
- Male
- Female
DOB
MM slash DD slash YYYY
School Name and Address
Please list any allergies, medical conditions or special needs.
Please list your child's activities, interests and hobbies.
Child 4 Name:
First Last
Sex:
- Male
- Female
DOB
MM slash DD slash YYYY
School Name and Address
Please list any allergies, medical conditions or special needs.
Please list your child's activities, interests and hobbies.
Child 5 Name:
First Last
Sex:
- Male
- Female
DOB
MM slash DD slash YYYY
School Name and Address
Please list any allergies, medical conditions or special needs.
Please list your child's activities, interests and hobbies.
Please write any other child-specific care instructions or additional children information here.
General Household Information
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Gate Code
Do you have weapons or other firearms in your home?*
- Yes
- No
If yes, please explain.
Do you have a security or survellience system in your home?*
- Yes
- No
If yes, please explain.
In Case of An Emergency
Emergency contacts should be adults other than parents and at least one should be local, if possible.
Name:*
Relationship:
Phone:*
Name:
Relationship:
Phone:
Pediatrician*
Advisor's Name
Care Preferences
The following questions are optional. However, the more information you provide us with the better. It helps us provide higher quality and more personalized care for your family.
Please describe your family's daily routine.
Please list your household rules.
What are your nutritional preferences?
Nannies will use this information to plan and prepare meals for your children.
How would you like a nanny to approach discipline while in your home?
Please provide any additional information that might help us provide the best possible care for your child(ren).
Medication Authorization Form
No medication shall be given by a Trusting Connections employee without written permission of the parent or legal guardian. All prescription medication must be in the original container with the child’s name, name of the physician, medication name, and medication directions written on the label. Trusting Connections Employees may not administer personal medication; only medication provided by the family may be given to the children. Note: TC employees will always have a "Temporary Authorization Form" on file which may be used to override the authorization granted below for a specific shift only.
Medication Authorization: Please select one of the following options.*
- I permit Trusting Connections employees to administer any and all medications necessary, prescription or non-prescription, if needed.
- I permit Trusting Connections employees to ONLY administer the following medications for the reasons specified below.
- I DO NOT permit Trusting Connections employees to administer medication of any kind unless written permission is given to administer medication on the Temporary Authorization form for the day(s) specified.
Please list the medications/dosages TC employees are permitted to administer. Please also specify which child(ren) this applies to.
PLEASE SIGN: I understand and agree to TC's Medication policies and agree to the level of authorization I have selected above.*
Driving Authorization Form
Written permission must be given for a Trusting Connections employee to transport children. The employee is required to observe all safety regulations including seat belt and proper car seat use. If the employee uses her own vehicle for on-the-job driving, she will be reimbursed at the national standard rate. Any mileage charges accrued will be noted on the client’s receipt. Employees are not permitted to install car seats into any vehicle other than their own. If a family vehicle is provided, all car seats must be installed by the client. Verbal consent will not be accepted.
Driving Authorization: Please select one of the following options.*
- I permit Trusting Connections employees to drive my child(ren) for any childcare-related reason.
- I permit Trusting Connections nannies to drive my child(ren) under select circumstances (Enter Below).
- I do not permit Trusting Connections nannies to drive my child(ren) for any reason, other than a legitimate emergency, unless written permission is given on the Temporary Authorization form for the day(s) specified.
Please explain. List locations the nanny is permitted to transport the children to and from and for what purposes this permission is granted.
Printed Name*
Signature*
Date*
MM slash DD slash YYYY
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