Contact Information:

Parent(s) FullName’s:

1

2House Address: Address:____________________________

City:_____________ State:_____Zip-code:_____________

House Phone # (_ _ _) - _ _ _ - _ _ _ _

Where parentswill be?Phone numberparents can bereached at?

1 (_ _ _) - _ _ _ - _ _ _ _

2 (_ _ _) - _ _ _ - _ _ _ _What time theparents will beback?

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Emergency Information:

Parents can be reached at? (_ _ _) - _ _ _ - _ _ _ _

Neighbors Number(if necessary) (_ _ _) - _ _ _ - _ _ _ _

Grandparents or Close Relatives (_ _ _) - _ _ _ - _ _ _ _

Local Police / Fire (911)!!

Child(ren) Information:

Name:

Age:

Gender:

Medication: (if yes, please explain howmany doses any what time taken)Any Allergies: (if yes, explain what andhow you prevent it)

Name:

Age:

Gender:

Medication: (if yes, please explain howmany doses any what time taken)Any Allergies: (if yes, explain what andhow you prevent it)

Name:

Age:

Gender:

Medication: (if yes, please explain howmany doses any what time taken)Any Allergies: (if yes, explain what andhow you prevent it)

Rates:

$10.00/ Hour

I will make sure your child(ren) are safe the whole time they are on my watch!My #1 priority is your child’s safety!!Your child will play games, have fun, do arts & crafts, go hide & seek and much morewhile I’m babysitting!While safety is my priority having fun will also be another! I don't want to be thebabysitter the kids says “didn’t play with us”, “yelled at us the whole time”, “wasn't fun”,I want to be the one they say “made me laugh”, “we played fun games”, “I want him tobabysit again!”During the time I babysit your child(ren), they will be in good hands, we will pick upafter our self's, make the house nice and clean! Instead of doing these activities in boringways we will make games and contests and have fun with it!I can also make them dinner, if necessarily! Also, put them into bed!Okay enough of me telling you what I’ll do and let me tell you a little bit about me!

Let me tell you a little bit about me!My name is Nicholas Rosselli. I am 14 years old and in the 8th grade! I have straight A’s& B’s . I am good with cooking, cleaning up, and much more! My hobbies are riding mybike and playing soccer! I like to make crafts, play board games, and I can help out withhomework! I have gone to a 3-hour Babysitting course as of: May 16, 2014!This Included-#1 THE SAFETYOFTHE CHILD(REN)!!-CPR, Choke Save, First Aid, and the basics of babysitting-Diapering-Bedtime-Feeding/Dinner-Fire Safety-Discipline

**Certificate attached LAST PAGE**

Questions:

1. Would you like me to feed the child(ren) ? (if yes, what food and what time) :

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2. Still wearing diapers? Yes or No (if yes, I change them!)

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3. When is bedtime? Any rules? Any specifications (like keep light on or door open acrack?)

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4. Handling the phone...would you like me to take messages? Any specifications?

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5. Entertaining the kid(s)...can they watch t.v./ movie? **ONLYG & PG**

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6. Any areas in the house off limits for kid(s) or ME?

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7. Is it OK to watch TV or listen to music at low level while kids are in bed? (**Answeronly for night shifts**)

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8. Do you have any pets I need to feed or take care of? (I yes, explain amount of food orhow to take care of?)

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9. (Depending on time of Day) Can the kid(s) be outside! **NO FRONT**

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10. Would you rather them put on sunscreen and/ or insect repellent?________________________________________________________________________

11. Kids Allergic to anything, or taking medication?

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12. Do they have any illness I should be aware of?

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If you would like to add anything, please do so below:

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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Cut this out and keep!

If you have any questions I can be reached at:

Name: Nicholas RosselliCell: (774) 417 - 1266Email: nickrosselli@comcast.net