Type of Care:

Child Care Newborn and Post-Delivery Care Senior Care Post-Surgical Care Household Assistant Pet Sitter Housekeeper

Type of Service:

Short-Term Care Pay-as-you-go Long-Term Care Referral Due Diligence

Client Name:

Email:

Mobile:

Home Number:

Office Number:

Best Number to Contact:

Current Street Address:

City:

State:

Zip

How Did You Hear About Us:

Google Search Engine Yahoo Bing Web Ad (top or side ad on Google) IGO La Jolla Pediatrics Parent Connection Other Physician or Dental Office Referral Email Letter Community Organization Auto Advertisement

Referred By (if applicable):

Location of Service if other than the address listed above:
Please include street address, city, state, and zip.

Client Name 2:

Email:

Street Address:

Home:

Office:

Best Number to Contact:

Schedule and Assessment

Please be as descriptive as possible when filling out the hours of care you will need.  Specify if you will need a.m., p.m., or 24 hour shifts.

Date of service (if not sure please indicate):

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

Please use this area to describe any special requests regarding your schedule needs:

Live-In

Live-Out

Driving

Driving children to activities

Misc. errands

Reading aloud

Meal planning and preparation

Grocery shopping

Changing bed linens

Sweeping

Making beds

Vacuuming

Dusting

Laundry

Household organization

Dog walking

Pet feeding

Plant maintenance

Mail pickup

Walks or outdoor activity

Please fill out the following checklist for Newborn/Post-Delivery Care only:

Sleeping in newborns room

Night feedings or participation in night feedings

Care of umbilical cord

Newborn Bathing

Birth of multiples

If applicable list how many:

C-Section delivery

ADLS (Activities of Daily Living)

Assistance dressing

Dementia

Alzheimer's

Smoking

Incontinence

Emptying Colostomy or Catheter Bag

Bathing Assistance

Recording (not administering) medication dosing

Lifting to stand

Oxygen or Nebulizer use

Terminally ill

Transport in or out of bed or wheelchair

Range of motion activities

Undergoing Dialysis

Undergoing Chemo or Radiation treatment

Feeding tubes

FOR ALL LOCATIONS:  Click here to fully review the Crunch Care Family/Client Application Agreement.  Please print full document for your records.  By entering my initials in the box to the right, I hereby agree to the terms and conditions stated above in this Client Application and to all the terms and conditions in the Crunch Care Family/Client Agreement.

I am entering my initials to confirm that I have been given the following information:  I have been told that TrustLine is California's registry of in-home child care providers, tutors and in-home counselors who have passed a background screening. It was created by the California Legislature in 1987 and is a powerful resource for parents hiring a nanny or baby-sitter. All caregivers listed with TrustLine have been cleared through a fingerprint check of records at the California Department of Justice. This means they have no disqualifying criminal convictions or substantiated child abuse reports in California. TrustLine is administered by the California Department of Social Services and the non-profit Child Care Resource and Referral Network. It is endorsed by the California Academy of Pediatrics. For more information visit www.trustline.org. An employment agency is prohibited by law from placing a child care provider unless the provider is a Trustline applicant or a registered child care provider. Parents can check if a provider is registered on TrustLine by calling 1-800-822-8490. You'll need to provide (1) the person's full name and (2) driver's license number.

Additionally, by entering my initials in the box to the right, I: (1) agree to provide all of my necessary billing information to Crunch Care; (2) agree to provide Crunch Care with a valid credit card for my billing; (3) understand and agree that Crunch Care shall charge my credit card for all fees, charges and costs pursuant to the Crunch Care, Inc. Family/Client Agreement; and (4) agree to pay all such fees, charges and costs on my credit card to Crunch Care.

By entering my initials to the right I understand on all Short-Term Care bookings there is a no refund policy on referral fees paid to Crunch Care.  Additionally if a booking is canceled at any time the day before or the day of the shift an additional $30 cancellation fee wil be charged to your credit card.   

Upon submittal of this form you will be taken to the site home page.  We will contact you shortly regarding your request. 

FOR URGENT REFERRAL NEEDS in addition to filling out this form please contact us by phone at 877-553-4231, ext. 1.  We will handle your request with a strong sense of urgency.

**Please print and retain a copy of your completed Client Application for your records.**