PARENT INFO FORM

Select those which apply: Y=Yes, N=No, D=Depends, S=Some

PERSONAL INFORMATION FOR EACH CHILD

(Please provide the following information about your children.)

Name | Sex | DOB | School Schedule

PARENTS MUST TAKE PRECAUTIONS TO MAKE FIREARMS INACCESSIBLE.

FAMILY LIFESTYLE 

Nanny Qualifications/Job Duties:

Please describe each child’s personality, development stage, special needs, health concerns, allergies, and medications.

*NOTE: The Client Acknowledgment and Release, Payment Agreement, and Guarantee Policy are listed below so you are fully informed. Once you have submitted the above Parent Info Form, we will email you a link to sign your official paperwork via Docusign so we can start the process. Scroll down this page to hit the "Submit" button.

Feel free to call or email if you have any questions. 

CLIENT ACKNOWLEDGMENT AND RELEASE

I/We, the undersigned, hereby acknowledge that I/we have engaged the services of ACN, NJ (the "Center"). I/We further understand that the Center specializes in the referral of dependent care provider candidates (the "Candidate(s)") for occasional, temporary, and ongoing dependent care.

I/We understand that upon hiring a Candidate for ongoing dependent care or for occasional or temporary care, I/we shall be required to pay the applicable Center referral fee (the "Fee"). If, however, I/we subsequently hire a Candidate for ongoing care, whom I/we have previously used for occasional or temporary care, the Fee assessed for the referral of an ongoing dependent care Candidate will then be payable.

I/We further acknowledge that the Center does not maintain an employer/employee relationship with any of the Candidates. Accordingly, I/we accept that it is my/our responsibility to interview any Candidates selected for referral by the Center and to perform an independent inquiry, in addition to any inquiry performed by the Center into each Candidate's references and background, prior to a final selection of any Candidate hired by me/us. I/We understand it is my/our responsibility to obtain from the Center all back-up paperwork on the Candidate I/we have hired.

Each of the undersigned further acknowledges that any and all information, including, but not limited to, the Candidate's file, is confidential and the property of the Center. Because I/we acknowledge that such proprietary information is confidential, I/we agree not to disclose to any person or entity the name and address or any other information relating to any Candidate.

In consideration of the services of the Center and of the personal benefits and advantages received by me/us as a result of these services and being fully aware of the potential risks and hazards inherent in hiring a person to provide care for a dependent, I/we unconditionally accept and assume any and all risks involved in hiring a Candidate referred to me/us by the Center.

Each of the undersigned exempts and releases ACN Holding, Inc., the Center, its directors, officers, shareholders, agents, and employees from all actions, causes of action, claims and demands for injuries, accidents, sickness and damages of whatsoever nature, which may be sustained by me/us or our dependent in consequence of using the services of the Center. 

Each of the undersigned, individually and as parent(s) and natural guardian(s), hereby agrees to indemnify and save harmless the Center from all injuries, losses, damages, and expenses, should any claim, demand or suit be made by or on behalf of my/our minor child(ren) in consequence of using the services of the Center.

This release extends and applies to all unknown, unforeseen, unanticipated, and unsuspected injuries, damages, losses and liabilities, and the consequences of them, as well as those, which may have been disclosed and presently known to exist. The provisions of any state, federal, local or territorial law or statute providing, in substance, that releases shall not extend to claims, demands, injuries or damages which are unknown or unsuspected to exist, at the time to the person executing such release, are expressly waived.

Any controversy or claim arising out of or relating to this Acknowledgment and Release shall be settled first by mediation and, if unsuccessful, then by arbitration. Such arbitration shall be conducted in accordance with the rules of the American Arbitration Association, and judgment upon the award rendered by the arbitrator(s) may be entered in any court of competent jurisdiction.

I(WE) HAVE READ THE ABOVE ACKNOWLEDGMENT AND RELEASE AND FULLY UNDERSTAND IT. 

PAYMENT AGREEMENT

Agreement (hereinafter called "Agreement") made on date entered below between Jacrac, LLC, a New Jersey corporation doing business as A CHOICE NANNY, (hereinafter called the "Service"), in Bergen County, State of New Jersey, and name entered below (hereafter called the "Client”)

In exchange for the services rendered and to be rendered, Client agrees to make the payments as promised in this Agreement.

1. Client has paid a one-time non-refundable Membership/Application Fee of $275.00 and has become a member of Service for the purpose of obtaining the assistance of Service in locating a person (hereinafter called "NANNY”), to assist in caring for child or dependent on a full time, part-time, on-going, or temporary basis.

2. Client agrees that if he/she/they use(s) the services of a Nanny referred by Service pursuant to the terms and conditions of this Agreement, Client shall be liable to Service for any and all fees specified in this Agreement. Client further agrees that if the Nanny is hired on a Temporary, Occasional, Part-time or Summer basis for any type of work, including non-dependent care services, and is later used on a more than Temporary, Occasional, Part-time or Summer basis, Client shall pay the appropriate fees for such increased services. Each of the undersigned further acknowledges that any and all information, including, but not limited to, the Candidate's file, is confidential and the property of the Service. Because I/we acknowledge that such proprietary information is confidential, I/we agree not to disclose to any person or entity the name and address or any other information relating to any Candidate. I/we further agree to compensate the Service a placement fee in the event that I/we hires or refers any candidate introduced to me/us by the Service to a third party who hires the services of the nanny within two years of introduction.

3. Nannies referred by Service are defined as care givers 18 years of age or over who come into Client's home or other place as designated by Client and care for children or other dependents. A Nanny shall in no event be an employee of Service, but rather shall be an employee of Client. The Client is responsible for any payroll taxes, benefits, etc. to the nanny.

4. Referral for on-going services of Nannies shall be classified as follows:

(a) FULL TIME: Care by which an ongoing and regular arrangement is made between Client and Nanny where the Nanny works 31 hrs./wk. or more.

(b) PART-TIME: 20-30 hours. Care by which an ongoing and regular arrangement is made between Client and Nanny where the Nanny works anywhere between 20 and 30 hours per week.

(c) PART TIME: 1-19 hours. Care by which an ongoing and regular arrangement is made between Client and Nanny where the Nanny works anywhere between 1-19 hrs. /wk.

5.  (a)If Client offers employment to Nanny and Nanny accepts offer, and for any reason, other than an unacceptable background check, Client changes his/her/their mind whereby Nanny does not begin work for Client, then Client pays only a nominal fee not to exceed $300.00 to help defray costs of administration, computer work and background checks.

(b)Client agrees to pay directly to Service a fee for the assistance provided in accordance with the schedule set forth below:

Fee Schedule*

Part Time: to 19 hrs/wk - 4.5 x Nanny's weekly salary (minimum fee $1,200)

Part Time: 20 - 30 hrs/wk - 4.5 x Nanny's weekly salary (minimum fee $1,800)

Full Time Live-out Nanny (Over 30 hours/week) - 4.5 x Nanny's weekly salary (minimum fee $2,400)

TutorCare™ (Sept. June, afterschool, school age children, max. 20hrs/wk) - 4.5 x Nanny's weekly salary (minimum fee $900)

Summer Nanny (maximum 12 weeks) - 2.5 x Nanny's weekly salary (minimum fee $600)

All Final Referral Fees are non-refundable with a conditional pro-rated Credit Guarantee of 16 weeks.

New Search Fee - $150.00, which is the cost to reactivate your file and start a new search ($75.00 applied to Referral Fee at time of hire).

*Subject to Change

6. a). All fees are due at the time the Nanny begins employment. The first day of hire/employment is considered the first day the nanny works for you, regardless of how many hours.

b). Payment may be made by cash, check, money order, or a major credit card.

Fees not received in Service's office when due will automatically be charged to Client's credit card and Client hereby authorizes such charges. Make checks out to A Choice Nanny. Checks may be sent to: 

Jacrac, LLC, A Choice Nanny

P.O. 132, Montvale, NJ 07645

c). Payment of fee must be guaranteed by a major credit card or paid in advance for the estimated fee. Credit card payments are charged to Client's credit card and Client hereby authorizes such charges according to the above Fee Schedule.

d). Credits against fees may be extended by the Service in accordance with Credit Policy in effect at the signing of this Agreement.

e). Credits against fees may be extended by the Service in accordance with Credit PoLicy in effect at the signing of this Agreement.

7. This Agreement cannot and should not be construed or interpreted as a partnership or joint venture between the Client and Service. Client acknowledges that he/she/they have signed the Client Acknowledgment Release.

8. Any controversy or claim above Small Claims Court limit arising out of or relating to this Agreement shall be settled by arbitration in accordance with the Commercial Arbitration Rules of the American Arbitration Association and judgment upon the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. The parties hereto agree that the arbitration shall be held at an office recommended by the American Arbitration Association in Bergen County, NJ·

9. The parties acknowledge that they have read and understand all the terms and conditions set forth in this Agreement. This instrument constitutes the entire Agreement and all prior negotiations and understandings have been merged herein. No modifications of this Agreement shall be valid unless in writing 

and executed by the parties.

A CREDIT CARD NUMBER IS NECESSARY BEFORE A SEARCH BEGINS. WE WILL CONTACT YOU SHORTLY FOR PAYMENT UPON PROCESSING.

Payment may be made by cash, check, money order, or a major credit card. Payments not received in Service's office when due will automatically be charged to Client's credit card and Client hereby authorizes such charges.

GUARANTEE POLICY

If, for any reason, the Nanny leaves or care is terminated within 16 weeks of hire, Client will receive a prorated credit towards a new Nanny based on the number of weeks the Nanny was employed. Client's final fee will be divided by 16 weeks and a credit will be given for the weeks the Nanny was NOT employed. This credit may be used at any time within one year of the Nanny leaving.

EXAMPLE: If the Final Referral Fee was $2,400.00 and the employment ends after four weeks, the credit towards a replacement Nanny will be: $2,400 divided by 16 guarantee weeks x 12 weeks remaining on guarantee. The credit would be $1,800.00.

Client hereby recognizes that our written Nanny and Parent Agreement is instrumental in the Nanny staying on the job. Client hereby acknowledges that this CREDIT GUARANTEE POLICY will be null and void without such an agreement, and that a copy of our Nanny and Parent Agreement must be received in Service's office within two weeks of hire.

RECEIVED AND ACKNOWLEDGED