Placement registration

This form is used to register your details with CHARTON BROWN® prior to a carer being matched to your needs and placed with you.

We will contact you to arrange for payment of the registration fee as applicable, after receiving your submission.

Required fields are marked with an asterisk ' * '.

Before you start

Please provide details of a person we can contact if we need to ask a question about your form submission:

Contact name: *
Contact email: *
Contact phone number: *

If you are a Family, complete Section 1a.
If you are an organisation or corporate client, please complete Section 1b.

1a - Family details (for family placement)

Father's name:
Father's occupation:
Father's working hours:
Father's business phone number:
Father's mobile number:
Mother's name:
Mother's occupation:
Mother's working hours:
Mother's business phone number:
Mother's mobile:
Home address:
Suburb:
State:
Home_Postcode:
Home phone number:
Email address:
Emergency contact name:
Emergency contact phone number
Emergency contact mobile number:
Relationship to family:

1b - Organisation details (for other placements)

Organisation name:
Organisation address:
Suburb:
State:
Postcode:
Organisation contact person:
Title/Role:
Email:
Phone:
Placement address:
Suburb:
State:
Postcode:

2 - Children to be cared for

	Child's name	DOB	Special requirements
1
2
3
4

3 - Carer/Placements requirements

Nanny	Mother's help
Sole Charge	Parent(s) at home
Full time	Part time
Live-in	Live-out
Nanny/House-keeper	Mixture of Sole Charge & Parents at home
Casual/Temp/Babysitting/Creche	Other:

Commencement date and end date:

From until

Daily start and finish times:

	Mon	Tue	Wed	Thur	Fri	Sat	Sun
Start
Finish

Type of home environment:

Pets at home	Religion:
Smoking at home	Other:

Live-in-Carer privileges (as applicable):

Own bathroom/toilet	Entertaining friends allowed
Phone access allowed	Other:

Vehicle use during placement:

No car required	Family/Organisation car available
Carer needs own car	Details of car use:

Carer duties:

Carer details	Household duties (if applicable)
Prepare and implement activities	Parent/Adult laundry
Plan and prepare children's meals	Prepare household meals
Clean and tidy	Grocery shopping
Accompany children to activities	Mopping, sweeping, vacuming, dusting
Bath and clothe children	Clean bathrooms, toilets, kitchen
Supervise homework and chores	Washing dishes and displosal of garbage
Full baby care	Pet related duties
Wash and iron children's clothing	Pool care duties

Do you have a house-keeper?

Will this change with the employment of a Carer?

How important is it to have your home clean and tidy?

Other information relevant to this placement (ideal personality, cultural environment, etc):

4 How did you hear about us?

How did you hear about CHARTON BROWN® Nanny Placement Agency? *

Internet search

Yellow pages

Friends/Referral

Other internet referral (please specify):

Expo (please specify):

Other (please specify):

5 - Method of payment

You agree to pay the nominated Registration fee and my Changed rate/Placement fee (to be determined). We will contact you to arrange payment.

Please select intended method of payment: *

Conditions of Engagement of a CHARLTON BROWN® Carer

- The Registration Fee is a 'one off' joining fee covering administration charges for the processing of your application. Services are deliverable after payment of the Registration Fee is received. LABOUR HIRE POSITIONS - Nannies are employed and paid by CHARLTON BROWN (CB). The family/organisation pays CB the negotiated rate. - The family/organisation is to communicate directly with CBG on all matters pertaining to the Nanny's placement. - CB will negotiate all employment and conditions on behalf of the nannies - All positions are reviewed on a six (6) monthly basis, or on request - CB issues receipts on confirmation of payment - Failure to notify the agency at least 24 hours prior to booking of a position will incur a $25 late fee. Cancellation of a position with less than 24 hours notice will incur a minimum charge of three (3) hours - Minimum 3 consecutive hour per session charge applies to all positions - The family/organisation agrees to permit the Workplace Health & Safety Representative from CB to, if required, inspect the place where care is to be provided for the purpose of complying with the Workplace Health & Safety Act and to complete a safety checklist. The family/organisation agrees to rectify any defects in the place of care which are discovered as a result of this inspection and to indemnify CB and its employees against any loss or damage which arises out of accidents & incidents which occur whilst a nanny or staff in the employment of CB is engaged under this agreement - Should the family/organisation directly engage a nanny introduced by CB, outside the terms of this agreement, within eighteen (18) months of the placement of the nanny, a placement fee of four (4) times the weekly payment (or equivalent) is to be paid directly to CB - In the case of the nanny using the family/organisation vehicle, the family/organisation is to ensure that this is covered by their own insurance - CB takes no responsibility for personal property damage incurred whilst the nanny is working PLACEMENT FEE POSITIONS - The family/organisation agrees to pay CB the negotiated placement fee - Failure to pay the placement fee within 14 business days will render the 3 month replacement guarantee void and unenforceable by the family/organisation ALL POSITIONS - All client and nanny introductions are confidential. Names, addresses and phone numbers must not be divulged to a third party. Infringements will be considered a breach of contract

Do you accept the above conditions of engagement? *

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