Client Registration Form

Thank you for choosing Hummel Family Care. To begin your placement journey, please complete the following forms. If you would prefer to discuss your specific needs before proceeding, we invite you to schedule a complimentary placement consultation, linked here.

First Name:

Last Name:

Email:

Phone Number:

Service Category

Preferred Start Date

Number of Children being Serviced:

Age of Children being Serviced:

Service Address:

Allergies?

Will pets be present? If so, please specify:

Family values/parenting philosophy we should consider:

Communication style preference (frequent updates, weekly check-ins, etc.):

Typical Weekly Schedule Requirements:

Additional household responsibilities (if any)

Additional Preferences or Requirements

Budget range for annual compensation:

How did you hear about Hummel Family Care?

I confirm that the information provided in this registration is complete and accurate to the best of my knowledge. (Please initial)

I understand that Hummel Family Care prioritizes discretion and privacy. I acknowledge that my family's information will be handled according to the privacy policy outlined in the service agreement. (Please initial)