FAMILY APPLICATION
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| Spouse/Guardian: |
Phone: |
| Street Address: |
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| City: |
State: Zip: |
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| Person(s) in need of services: |
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| Street Address: |
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| City: |
State: Zip: |
| Home Phone: |
Home Fax: |
| Email: |
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| How you would like to be contacted by FHI during work hours?Phone Email |
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| Emergency Contact: |
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| Relationship to person requiring services: |
Phone: |
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| Check the types of providers your family is requesting:
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Live-In, Full Time Companion: YesNo Live-Out, Full Time Companion: YesNo |
| Part-Time Companion: YesNo Temporary Companion: YesNo |
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| FAMILY INFORMATION: |
Are there any special needs or medications to be administered?
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| Do any family members smoke? YesNo |
| Will you allow smoking in your home? YesNo |
| Are there any other adults living in the home? YesNo |
| Is there any domestic violence in our home? YesNo |
| Is any family member physically or mentally handicapped? YesNo |
| Do any members of your family have alcohol or substance abuse problems? YesNo |
| Any special observances (i.e. diet)? |
Family interests and hobbies?
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Please describe your community?
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| PROVIDER INFORMATION: |
Have you ever employed a companion? YesNo |
If yes, please describe the relationship (length of stay, how relationship terminated, etc.)?
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Do you require a driver? YesNo |
| Are you able to provide a family car for the companion during working hours? YesNo |
| Are you able to provide a car for the companion outside of workng hours (live-in only)? YesNo |
Do you require/prefer your companion to have any special skills (cooking, drivng, etc.)?
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Please describe your expectations of your Family Helper provider's responsibilities
(specify working hours, household chores, etc.)?
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| Are you able to provide a separate bedroom for your provider (live-in only)? YesNo |
| What date would you like your Family Helper to begin? |
| What is the salary range you are willing to pay? |
| Are you willing to provide health benefits? YesNo |
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| Please list the folowing information of two personal references whom you have know for at least two years: |
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| How did you hear about Family Helpers? |
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| AGREEMENT: |
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Agreement made this day of 2010, between ,
residing at , , NY hereinafter referred to as "Client" and FAMILY HELPERS, INC., a domestic New York Corporation, 125 Main Street, Dobbs Ferry, New York 10522, hereinafter referred to as "FHI".
1. Upon submission of this agreement with a nonrefundable Consultation Fee of $75.00, Client agrees to retain FHI to search for a "Helper", more fully described as:
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2. For the services of obtaining a domestic employee ("Helper"), client agrees to pay FHI referral fee as follows:
Full Time Live In - 12% of Helper's Annualized Gross Compensation, (Minimum Fee $2,400.00)
Full Time Live Out - 12% of Helper's Annualized Gross Compensation, (Minimum Fee $1,800.00)
Part Time - 12% of Helper's Annualized Gross Compensation, (Minimum Fee $1,200.00)
Temporary - 20% of Helper's Gross Compensation, (Minimum $25/day)
Said Referral Fee shall be due in full upon telephone acceptance by the Client of FHI's referred applicant. Payment of said fee must be received by FHI within five (5) days from the date of acceptance or prior to the arrival of the Helper in Client's home, whichever is earlier. Client understands that the Helper may not arrive in the Client's home prior to receipt by FHI of the Referral Fee. FHI agrees that the Payment of the Consultation Fee will be credited towards the Referral Fee due.
If the payment is not received within 5 days of the due date, then the Helper shall remain active with FHI and continue interviewing for a position with other FHI clients. If payment is not received within ten (10) days of the due date, or if Client fails to enter into a written employment agreement with the Helper, any guarantee hereinafter described, then becomes null and void.
A 1.5% per month service charge (18% per year) will be charged on all accounts unpaid after ten (10) days. Client will also be responsible for all collection costs, including attorney fees and court costs.
3.1 Should the Client-Helper relationship terminate within ninety days of the commencement of full-time employment ("the guarantee period"), FHI agrees to provide Client with one replacement search at no additional charge to Client, and the Client is not entitled to any refund.
Should the placement be for a part-time or summer placement terminate, the "guarantee period" shall be thirty days.
3.2 If a full-time employment relationship lasts more than ninety days, but less than six months, Client shall not be entitled to any refund or replacement from FHI. Client may request a search for a replacement Helper. The referral fee for such replacement will be 50% of the normal referral fee. Upon such placement a ninety day guarantee in accordance with the provisions of paragraphs 3.1 and 3.2 shall commence.
3.3 FHI may at its option provide Client with a refund of 50% of the referral fee in lieu of the replacement provisions of paragraph 3.1.
4. This agreement shall be binding only upon the parties hereto and shall not include any third party. FHI shall not be a party to any agreement entered into between Client and the Helper.
5. FHI will use reasonable efforts to provide Client with a placement, but FHI assumes no liability or responsibility to confirm and verify all references and information supplied to the Client in the course of such placement. Client may confirm and verify references and other information. The Client understands and agrees that FHI, its employees and its agents are not responsible for events beyond their control, nor in the absence of willful neglect, is FHI, its employees or its agents liable for the acts or omissions of the Helper, nor for any claims of whatever nature the Helper may have against the Client. Client hereby agrees to indemnify and hold harmless FHI, its agents and employees from any and all such claims.
6. Client shall refrain from making any private agreement with the Helper or from taking any action which is inconsistent with this agreement or which has the effect of avoiding any of the Client's obligations hereunder. Such private agreements and actions include, but are not limited to, actions which would enable the Client or any other person to avoid payment of the registration and/or placement or referral fees due to FHI, as for example, if Client gave the name of the Helper to another person who subsequently employs the Helper or a friend of the Helper. Client agrees not to employ any applicant referred by FHI for eighteen month's time except in accordance with the terms of this agreement. Client also agrees not to disclose to anyone the names or addresses or telephone numbers of any Helper referred to the Client. If Client violates any of the provisions of this paragraph, Client shall be liable for two times the placement fee of the said Helper that would otherwise be due to FHI from Client or third party; Client shall also be liable for any attorney fees and other costs of collection.
7. This Agreement contains the entire understanding between the parties and may not be changed or modified except in writing signed by both parties, and shall be governed by the laws of the State of New York.
IN WITNESS WHEREOF, the parties have executed this Agreement by clicking on the SUBMIT key. Clicking the SUBMIT key is equivalent to signing the document
Please enter the date of this agreement:
Credit Card Information used for Consultation Fee:
Name on Credit Card:
Credit Card Type:
Credit Card Number:
Expiration Date (mm/yy):
Security Code:
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