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.
Please indicate if you have any preferences or special requests of a Caregiver.
Age Preference Yes/No If yes, explain:
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.