Larah Au-Pairs

Telephone: 01932 341 704

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Elderly Companionship - APPLICATION FORM

   
Date Required
Name of Contact Person
Contact Telephone Number
Email Address
Relationship To Client
Description Of Accommodation
Have they had a companion before?
Are there any other employees?
   
DETAILS OF CLIENT  
   
Name
Contact Telephone Number
Age
Sex
Nearest Town
Nearest Airport
Nationality
Religion
Main Language Spoken
Other Languages Spoken
Type Of Residence
Any pets?
Would you accept a smoker?
Do you require a driver?
   
HISTORY  
   
Describe physical and mental condition
Require assistance to walk?
Any special diet?
If you answers yes to the above question, please specify:
Any other information?
Duties required? (Tick all that apply) Help to get up and going to bed
  Bathing and showering
  General housework
  Laundry
  Assisting to toilet
  Shopping
  Other
If you ticked Other, please specify?
   
HOURS AND PAY  
   
How many hours per day required?
Weekends off?
Weekly Net Salary
   
I have read the Terms And Conditions View Terms & Conditions (New Window)
   
 
 

 

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