SECURE BOOKING
Extended Validation Certificate
How did you hear about us? (Referred by) Repeat customer Internet Concierge Phone book Word of Mouth
Personal Information
First name:
Last Name:
Cell Phone:
Home Phone:
Email address:
Children Information
Name Age
Child 1:
Child 2:
Child 3:
Child 4:
Child 5:
Babysitting Information
Location
Town:
Date 1: From 0 1 2 3 4 5 6 7 8 9 10 11 12: 00 15 30 45 AM PM To 0 1 2 3 4 5 6 7 8 9 10 11 12: 00 15 30 45 AM PM
Date 2: From 0 1 2 3 4 5 6 7 8 9 10 11 12: 00 15 30 45 AM PM To 0 1 2 3 4 5 6 7 8 9 10 11 12: 00 15 30 45 AM PM
Date 3: From 0 1 2 3 4 5 6 7 8 9 10 11 12: 00 15 30 45 AM PM To 0 1 2 3 4 5 6 7 8 9 10 11 12: 00 15 30 45 AM PM
Date 4: From 0 1 2 3 4 5 6 7 8 9 10 11 12: 00 15 30 45 AM PM To 0 1 2 3 4 5 6 7 8 9 10 11 12: 00 15 30 45 AM PM
Date 5: From 0 1 2 3 4 5 6 7 8 9 10 11 12: 00 15 30 45 AM PM To 0 1 2 3 4 5 6 7 8 9 10 11 12: 00 15 30 45 AM PM
Date 6: From 0 1 2 3 4 5 6 7 8 9 10 11 12: 00 15 30 45 AM PM To 0 1 2 3 4 5 6 7 8 9 10 11 12: 00 15 30 45 AM PM
Date 7: From 0 1 2 3 4 5 6 7 8 9 10 11 12: 00 15 30 45 AM PM To 0 1 2 3 4 5 6 7 8 9 10 11 12: 00 15 30 45 AM PM
Sitter Preference
No preference Male Female
Other comments, questions, requests or extra dates:
Deposit Information
Your credit card information is needed to reserve a sitter. This information will be held until 1 week before your first appointment, when you will be charged a non-refundable deposit of $36 per appointment (the deposit is deducted from your total, and the remaining balance is paid to the sitter). If you wish to cancel, please do so before this time to avoid penalty.
This is a Secure Site, however, if you prefer to give this information over the phone, please call our office after submitting the form.
Card type: (Type) Visa Master Card American Express Discover
Name on card:
Card Number: Exp:
CVV (security code on back of card):
Billing address:
City:
(If in US) State: (State) Outside US AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip:
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