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.
You may receive infrequent and relevant marketing communications from Norma Lewis Nannies Agency or Norma Lewis Training, but you can unsubscribe at any time if these emails are not of interest to you, by emailing norma@normalewisnannies.co.uk
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
(For full details on Registration and Administration charges please read Agency Terms, Clause 5.)
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Details of Person Completing the Form
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Full name and title * |
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Address * |
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Postcode* |
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Home telephone number* |
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Work telephone number* |
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Email Address* |
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Relationship to person requiring companion* |
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Please supply the name and address of the person responsible for payment of the invoice* |
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Details of the Person Who Needs the Companion
(If different to above, otherwise enter N/A )
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Persons full name and title * |
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Persons address* |
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Persons Postcode* |
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Persons home telephone number* |
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Religion* |
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Nationality* |
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Age* |
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Emergency Contact 1 name and telephone number* |
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Emergency Contact 2 name and telephone number* |
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About the Job |
Is this position* |
Live In Live Out Either |
When do you need someone to start |
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What is the minimum length of the contract
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What is the maximum length of the contract |
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How many days per week is the Companion required to work |
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How many hours each day |
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What will you pay your companion per week (NET) |
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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 |
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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 |
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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 |
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General Duties and Daily Routine |
Is cooking required |
Yes No |
Please describe any special dietary requirements |
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When should the main meal of the day be provided |
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At what time (approx) does the client wake and get up
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At what time (approx) does the client retire for the night |
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Is assistance required at night |
Yes No |
If so how often, and for what |
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Does the client rest during the day |
Yes No |
At any particular time(s) |
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Does the client have regular visitors (both friends and family) |
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Do they call at regular times / days |
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Does the District Nurse call |
Yes No |
If so how often and to do what |
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Does the client have any hobbies or interests |
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Does the client have a favourite TV programme |
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Is Help Required |
With shopping |
Yes No |
Accompanying to hospital appointments |
Yes No |
Escorting to place of worship |
Yes No |
Any other errands |
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Personal Details and Duties |
Reason for clients need of Companion |
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Height of client |
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Weight of client |
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Is there any loss of speech, hearing or sight |
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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 |
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Is Mobility Restricted |
Please Describe
(e.g. stand/walk unaided, climb stairs, Use a wheelchair etc)
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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 |
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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 |
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Do they wander |
Yes No |
Please give any further information you feel may be helpful including the general mood of the client |
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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
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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 |
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How many bathrooms |
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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 |
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Bus Stop |
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Train / Underground |
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Main Shopping Center |
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Library |
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Restaurants Pubs Cafes & Bars |
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Museums |
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Nightclub |
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Which is your nearest train or tube station |
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And Finally |
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Please describe your family and household - e.g. "we are a friendly but hectic household..." |
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Would you like any information on First Aid courses for your companion* |
Yes No |
How did you hear about Norma Lewis Nannies * |
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Have you registered with any other agencies, and if so which ones* |
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Family name* |
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Date * |
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