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 $35 (more than 24 hr notice) or $45 (less than 24 hr notice and holidays.)

I understand that if a sitter is found, I will be invoiced $35 (more than 24 hr notice) or $45 (less than 24 hr notice and holidays.) 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
What pets do you have? (if none 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
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