Information Request Form ... This is a SECURE form. Your information is encrypted for your protection.
CHILDCARE SOLUTIONS
2101 Richmond Rd. Suite 1000
Beachwood, Ohio 44122

A membership organization, Childcare Solutions^®
has been creating in-home care relationships for
Cleveland area families since 1991.

We are pleased to offer personal referral services to families seeking pre-qualified, caring and experienced In-Home Child Care, NannyCare and Baby-sitters, as well as Non-Medical Elder-Care, Companion Care and Transportation Services.

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* = Required Information

Tell us About You...

*First Name:		*Last Name:
*Street Address:
*City:		*State: AZ AK AR AL CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MS MO MN MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY --	*ZIP Code:

*Home Phone:

Work Phone:

Email:

Cell:

I am a: Parent/GuardianSeniorCompany RepresentativeDaycare Center *Age: AdultUnder 18
* You must be at least 18 years of age to enter into a contract for care.

Tell us how we should contact you... (please select all that apply)

At Home:				At Work:
Daytime:				Evening:
Weekdays:				Weekend:

Other (please describe)

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About our services...

What services are you interested in? (please select all that apply)

Live-In Help:		Live-Out Help:
In-Home NannyCare:		Full-Time:
In-Home Newborn Care:		Part-Time:
Nanny Share:		In-Home Companion Care:
Help With Errands/Shopping:		Baby-Sitting:

Other (please describe)

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Tell us about your needs...

Who will be cared for? (please select all that apply)

Infant			Toddler			Pre-Schooler
Pre-Teen			Teenager			An Adult
A Senior

Other (please describe)

Tell us about the schedule you would like to fill...

DAY(S) per week? ---1234 Mon-Fri, 5Sat-Sun, 2

HOURS per day? ---456788 +

TYPE of position? please selectPermanent (>3 months)Temporary (<3 months)Occasional (advance notice)On-Call (emergency or back-up)One-Time UseCorporate Inquiry

Tell us in your own words what you are looking for... (required)

Who referred you to us?

Please let us know if you were referred by please select no one A Friend A Neighbor A Business Associate Other

How did you come to find this website? please select... Google/Yahoo/MSN search other Search Engine A Magazine Ad A Newspaper or Magazine Article A Blog Article/Posting A Friend/Neighbor INA Website Care.com Website other Nanny Search Website Other

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Once you click the "SEND" button (above) we will have all the information we need to begin to assist you in your search.
We will contact you as quickly as possible to discuss your needs in detail.

Childcare Solutions Respects Your Privacy.
We will never add your name, email, or other personal information to ANY mailing list.

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CHILDCARE
SOLUTIONS
Beachwood, Ohio     216-223-8090

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