Stellar Sitters One-Week Placement Request Form

1One-Week Placement Request > 2Commitment Form > 3Review Your Entry
How did you hear about Stellar Sitters?
I understand if a successful placement is made, I will be charged a $145 placement fee/week.

I understand if a successful placement is made, I will be charged a $145 placement fee/week. 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 children from a different family? (i.e. niece/nephew, cousin, friend's child, etc.)

Are any of the children from a different family? (i.e. niece/nephew, cousin, friend's child, etc.) Yes No
If yes, please explain.
Do you have any pets?

Do you have any pets? Yes No
If you have pets, please list what kind of pets you have.
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 question, 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
Please list the 4-7 consecutive days/dates/times you are in need of a sitter.
If you would like to request a sitter(s) please list here:
If the requested sitter(s) isn't available, are you open to a new sitter?
If one sitter isn't available for all of the requested days, would you be open to having multiple sitters? We will do our best to fulfill your placement need with the least number of sitters as we understand the importance of consistency.

If one sitter isn't available for all of the requested days, would you be open to having multiple sitters? We will do our best to fulfill your placement need with the least number of sitters as we understand the importance of consistency. Yes No