Your Name: Address: City: Zip: Home Phone: Work: Cell: Email Address: Spouse/Partner Name: Spouse/Partner Work Phone: Tell us about your child(ren) Names and Dates of Birth: Please let us know if there are any special needs regarding your child(ren) that TLC should be aware of when placing a Caregiver in your home, i.e. physical disability, allergies, special medications, ADHD, ADD. This information is strictly used to better place a Caregiver in your home. Special Needs: Caregivers Profile Please indicate if you have any preferences or special requests of a Caregiver. Age Preference Yes/No If yes, explain: Nonsmoker Yes/No: Transporting Yes/No: Car Supplied to transport Yes/No: Do you have any pets? Type and number of pet(s): How did you find out about TLC?:
Please fill out and return to TLC either by email, (Click on "Send e-mail" button) or by Fax, 770-410-4779.