Stellar Sitters One-Time Placement Request Form

1One-Time Placement Request > 2Commitment Form > 3Review Your Entry
How did you hear about Stellar Sitters?
I understand that if a sitter is found, I will be invoiced $49 (more than 24 hr notice) or $59 (less than 24 hr notice and holidays) for each date I need a sitter OR I can purchase a Placement Package and have the placement(s) deducted from the package.

I understand that if a sitter is found, I will be invoiced $49 (more than 24 hr notice) or $59 (less than 24 hr notice and holidays) for each date I need a sitter OR I can purchase a Placement Package and have the placement(s) deducted from the package. Yes, I understand. No, I have questions.
Parent /Guardian 1 Parent /Guardian 1 First Last
Parent / Guardian 2 Parent / Guardian 2 First Last
Primary Email
Primary Phone Primary Phone - ### - ### ####
Secondary Phone Secondary Phone - ### - ### ####
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
If sitting location is other than home address, please list below. If sitting location is other than home address, please list below.
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Child 1 Child 1 First Last
Sex of Child 1

Sex of Child 1 Male Female
Birth Month and Year of Child 1
Current Age of Child 1
Allergies/Medications/Special Needs for Child 1
Child 2 Child 2 First Last
Sex of Child 2

Sex of Child 2 Male Female
Birth Month and Year of Child 2
Current Age of Child 2
Allergies/Medications/Special Needs for Child 2
Child 3 Child 3 First Last
Sex of Child 3

Sex of Child 3 Male Female
Birth Month and Year of Child 3
Current Age of Child 3
Allergies/Medications/Special Needs for Child 3
Child 4 Child 4 First Last
Sex of Child 4

Sex of Child 4 Male Female
Birth Month and Year of Child 4
Current Age of Child 4
Allergies/Medications/Special Needs for Child 4
Child 5 Child 5 First Last
Sex of Child 5

Sex of Child 5 Male Female
Birth Month and Year of Child 5
Current Age of Child 5
Allergies/Medications/Special Needs for Child 5
Are any of the kids listed from a different family? (i.e. niece/nephew/cousin, friend's child, etc.)

Are any of the kids listed from a different family? (i.e. niece/nephew/cousin, friend's child, etc.) Yes No
If yes, please explain.
If you would like to request a sitter(s) please list here:
If the requested sitter isn't available are you open to a new sitter?
What pets do you have? (please specify what kind; if you don't have pets please write "none")
Will a parent be working from home while the sitter is in your home?

Will a parent be working from home while the sitter is in your home? Yes No
Will the sitter be required to transport the children?

Will the sitter be required to transport the children? Yes No
If you answered yes to the above, please explain.
If you live a significant distance from where the sitter lives (15+ minutes) are you willing to pay extra for gas/drive time?

If you live a significant distance from where the sitter lives (15+ minutes) are you willing to pay extra for gas/drive time? Yes No
Additional Information you would like to share
First day that a sitter is needed (this helps confirm that the day and the date match up)
First date sitter is needed First date sitter is needed / MM / DD YYYY
Start Time Start Time : HH MM AM/PM
End Time End Time : HH MM AM/PM
Second day that a sitter is needed (this helps confirm that the day and the date match up)
Second date sitter is needed Second date sitter is needed / MM / DD YYYY

Leave this date blank if you are only requesting one date.
Start Time Start Time : HH MM AM/PM
End Time End Time : HH MM AM/PM
Third day that a sitter is needed (this helps confirm that the day and the date match up)
Third date sitter is needed Third date sitter is needed / MM / DD YYYY

Leave this date blank if you are only requesting one date.
Start Time Start Time : HH MM AM/PM
End Time End Time : HH MM AM/PM
Fourth day that a sitter is needed (this helps confirm that the day and the date match up)
Fourth date sitter is needed Fourth date sitter is needed / MM / DD YYYY

Leave this date blank if you are only requesting one date.
Start Time Start Time : HH MM AM/PM
End Time End Time : HH MM AM/PM