London Nanny agency places companions and housekeepers

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PLEASE ENSURE YOU HAVE READ THE FEES AND TERMS OF NORMA LEWIS NANNIES. SUBMITTING THIS COMPLETED FAMILY REGISTRATION FORM SHOWS ACCEPTANCE OF THESE FEES AND TERMS.
http://www.normalewisnannies.co.uk/families/fees/
http://www.normalewisnannies.co.uk/general-information/terms/
By submitting this form, you agree that we may contact you by ‘phone, email, or other means. We promise to keep your personal information safe and will never sell, share, or distribute it to a third party.
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By law we cannot start the work you have asked us to do on your behalf before 14 days after the date of the contract have elapsed. This is to protect you under rights of cancellation under the Consumer Contract Regulation 2013. If you wish to waive these cancellation rights to enable us to proceed with the work immediately, please sign and date at the end of the following clause.

“SUBMISSION OF THE FORM SHOWS THAT “WITH REGARD TO THE CONTRACT DATED (today’s date) ----- AND MY CANCELLATION RIGHTS UNDER THE CONSUMER CONTRACTS REGULATION 2013, I HEREBY WAIVE SUCH RIGHTS AS I WISH YOU TO COMMENCE WORK UNDER THE TERMS OF THE CONTRACT WITH IMMEDIATE EFFECT, AND I UNDERSTAND THIS WILL RENDER ME LIABLE FOR ANY PROPER CHARGES MADE UNDER THE TERMS OF THE SAID CONTRACT.
Date / Signature

In all instances:

Agreement in writing from the Client will be required prior to work commencing.
The minimum charge Agency fee will apply for any permanent placement.
Should a Client source an Applicant from elsewhere, or withdraw the vacancy, an automatic Administration fee will be charged.

(For full details on Registration and Administration charges please read Agency Terms, Clause 5.)

Yes No
Details of Person Completing the Form
Full name and title *
Address *
Postcode*
Home telephone number*
Work telephone number*
Email Address*
Relationship to person requiring companion*
Please supply the name and address of the person responsible for payment of the invoice*
Details of the Person Who Needs the Companion (If different to above, otherwise enter N/A )
Persons full name and title *
Persons address*
Persons Postcode*
Persons home telephone number*
Religion*
Nationality*
Age*
Emergency Contact 1 name and telephone number*
Emergency Contact 2 name and telephone number*
About the Job
Is this position*	Live In Live Out Either
When do you need someone to start
What is the minimum length of the contract
What is the maximum length of the contract
How many days per week is the Companion required to work
How many hours each day
What will you pay your companion per week (NET)
Do you accept that you are liable for Statutory Holiday pay for your Employee*	Yes No
Do you accept that you are liable for her tax and N.I contributions*	Yes No
Do you agree to issue a written contract*	Yes No
Will you accept a smoker	Yes No
Can they smoke in the house	Yes No
Do you need a driver	Yes No
If yes for what type of journeys
Will you provide the car	Yes No
If yes is the vehicle roadworthy, fully taxed and insured, with a current MOT	Yes No
NB If a Motability vehicle, please ensure that Motability have been notified.
Is the car	Auto Manual
May the companion have use of the car for themselves	Yes No
N.B. It is your responsibility to ensure that the companion has the standard of driving you require
Do you require the companion to travel with you	Yes No
If yes then Europe or Worldwide
Do you have any pets	Yes No
Is help required with them	Yes No
Do you employ a cleaner	Yes No
If so how often
General Duties and Daily Routine
Is cooking required	Yes No
Please describe any special dietary requirements
When should the main meal of the day be provided
At what time (approx) does the client wake and get up
At what time (approx) does the client retire for the night
Is assistance required at night	Yes No
If so how often, and for what
Does the client rest during the day	Yes No
At any particular time(s)
Does the client have regular visitors (both friends and family)
Do they call at regular times / days
Does the District Nurse call	Yes No
If so how often and to do what
Does the client have any hobbies or interests
Does the client have a favourite TV programme
Is Help Required
With shopping	Yes No
Accompanying to hospital appointments	Yes No
Escorting to place of worship	Yes No
Any other errands
Personal Details and Duties
Reason for clients need of Companion
Height of client
Weight of client
Is there any loss of speech, hearing or sight
Is Additional Help Needed With
Getting out of bed	Yes No
Dressing	Yes No
Ensuring meals are eaten	Yes No
Bathing	Yes No
If yes are there any special aids such as a seat across the bath
Is Mobility Restricted
Please Describe (e.g. stand/walk unaided, climb stairs, Use a wheelchair etc)
Toilet Assistance
Is any help required with toileting	Yes No
Getting to the toilet	Yes No
Is there a degree of incontinence	Yes No
Are aids available (e.g, pads)	Yes No
Do they go to the toilet at night	Yes No
How Often
Is help needed	Yes No
Medication
Does the client take medication	Yes No
How much help is required with medication	No help is required Companion to prompt Companion to assist Companion to administer
Confusion
Does the client get confused	Yes No
If so to what extent
Do they wander	Yes No
Please give any further information you feel may be helpful including the general mood of the client
I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO ENSURE THAT THE COMPANION HAS A LIST OF MEDICATIONS FOR THE CLIENT 24 HOUR EMERGENCY CONTACT NUMBERS, INCLUDING THOSE OF KEYHOLDERS
Your Home and Area
Where is your home	Village city suburb city center
Do you own or rent your home *	Own Rent
Is your home	Detached Semi Detached Bungalow Terraced Flat
How many bedrooms
How many bathrooms
Where is the client's Bedroom	Upstairs Ground Floor
Where is the companion's room	Upstairs Ground Floor
If a Live-in position please describe your companion accommodation	NB All companions must be allocated a separate bedroom.
Is there a washing machine	Yes No
Is there a a tumble dryer	Yes No
Is there a garden	Yes No
Computer / internet facilities	Yes No
Is it wireless internet	Yes No
May the companion have friends in the home	Yes No
How Long Would It Take to Reach the Following by Walking, Bus or Train/Tube
Local shops
Bus Stop
Train / Underground
Main Shopping Center
Library
Restaurants Pubs Cafes & Bars
Museums
Nightclub
Which is your nearest train or tube station
And Finally
Please describe your family and household - e.g. "we are a friendly but hectic household..."
Would you like any information on First Aid courses for your companion*	Yes No
How did you hear about Norma Lewis Nannies *
Have you registered with any other agencies, and if so which ones*
Family name*
Date *