<p> SUPER SITTERS, INC EMPLOYER’S NAME SECOND FAMILY NANNY’S NAME FIRST DATE ARRIVE DEPART EXTRA FEE FOR SICK CHILDREN $5 HOUR</p><p>ADDRESS NANNYS TOTAL HOURS </p><p>DIRECTIONS RATE PER.HOUR $</p><p>CHILD TIP</p><p>LOCAL PHONE TOTAL$ CELL PHONE</p><p>ON CALL SERVICE PHONE # 7885080 CELL # 7203836 PO BOX 988 S.V.ID.83353</p><p>CONSENT TO TREATMENT (Minor or not competent) We, the undersigned guardians or parents of ______do hereby consent to any emergency medical treatment needed in our absence.</p><p>SPECIAL INSTRUCTIONS</p><p>List any known allergies or medical conditions or medications to be given by nanny</p><p>Give permission to leave the premise, special instructions for bed, bath, etc.</p><p>Do you authorize anyone beside those listed on this sheet to enter this premise?? ______List emergency phone # and/or where you can be reached</p><p>CONDITIONS 1. A four-hour minimum is required after 5PM and a five-hour minimum before 5PM. 2. If reservations are canceled within 48 hours of scheduled time, the full time for the original booking will be payable. 3. Employers arriving home earlier than planned must pay for time scheduled. 4. Charges for On-Call Nanny services are payable each day upon completion for that days work by cash or check 5. Nannies are not authorized to transport children in motor vehicles. 6. ALL SCHEDULING OF NANNY SERVICES MUST BE MADE THROUGH SUPER SITTERS. Employer will be held accountable for full payment of amount due, special handling/investigative fees ($175.00 Hr.) and any legal fees if scheduling is done between Employer and Nannies without notifying SUPER SITTERS. If a Nanny referred to Employer is employed without the knowledge and concurrence of SUPER SITTERS, Employer will be liable for the full placement fee normally charged for such placement. 7. SUPER SITTERS is a nanny referral service. SUPER SITTERS does not guarantee the Employer will be satisfied with Nanny or Nanny’s performance. Under no circumstances shall SUPER SITTERS or its representatives be held liable to Employer by reason of any claim Employer has against Nanny, or by reason of any acts of omissions of Nanny hired by Employer. Employer agrees to indemnify SUPER SITTERS and hold it and its representatives harmless from any and all costs or expenses(including, without limitation, reasonable attorney fees) arising out of any claim against SUPER SITTERS or its representatives relating in any way to Nanny’s employment</p><p>EMPLOYER HAS READ, UNDERSTANDS AND ACCEPTS THE AGREEMENT</p><p>DATE ______SIGN ______PRINT______</p>