Please fill out the form below

For Corporate Backup Care Service Request

Corporate Backup Care Request For Service

To request services, please click the "Next" button below and complete your Request for Service form.

Contact Information

Name *

Email *

Contact Number *

Address *

City *

State *

Postal code *

HOTEL INFORMATION

Hotel Name *

Hotel Address *

Concierge Name

Room #

Type of Hotel service being requested.

Child Sitting

Adult Sitting

Pet Sitting/Walking

CHILD CARE INFORMATION

Number of Children *

Child's Name/ Age/ Gender *

What is the relation to the child/ren requiring care? *

Do you wish to have your child/ren taken outside of the hotel and/or building? *

Yes

If so, specify where child to be taken out.

How long child to be taken out

Please specify any allergies or health concerns or existing known health conditions

Please specify if there are any special needs/ requirements or requests? *

Does the Guest give permission to the Caregiver to take photographs and/or videos for the limited purpose(s) communicated between the Guest and Caregiver *

How can we meet your expectations?

ADULT CARE INFORMATION

Number of Adults *

Name/ Age/ Gender of adult(s) in need of care. *

What type of adult care is needed? Please specify.

Is the adult required to take medication daily? If so please specify.

Does the guest wish for the adult to be taken out?

Yes

Please specify where adult is to be taken out.

How long adult taken out

Emergency Contact Name

Emergency Contact Number

Is a Confidentiality Agreement Required?

Yes

If required, please upload Confidentiality Agreement.

PDF, JPG

Is travel assistance required?

Yes

What is the arrival city?

Length of stay required

Specify Transportation Type

If travel by air please specify

PET CARE INFORMATION

Pet Service Type

Number of Pets

Pet name weight breed

Pet Personality

Do you wish for us to take your pet outside?

Yes

Specify where to take pet

How long pet outside

Does the pet have any sensitivities or allergies? Please specify

Does your pet require medication?

Yes

If pet is on any medication, Please specify

CARE SCHEDULE

Date service requested 1 *

Start time 1 *

End time 1 *

Date service requested 2

Start time 2

End time 2

Date service requested 3

Start time 3

End time 3

Date service requested 4

Start time 4

End time 4

Date service requested 5

Start time 5

End time 5

Date service requested 6

Start time 6

End time 6

Date service requested 7

Start time 7

End Time 7

Do you need to schedule more than a week in advance? *

Yes

SECOND WEEK SCHEDULING INFORMATION

Date 8 Requested

Day 8 Start

Day 8 End

Date 9 Requested

Day 9 Start

Day 9 End

Date 10 Requested

Day 10 Start

Day 10 End

Date 11 Requested

Day 11 Start

Day 11 End

Date 12 Requested

Day 12 Start

Day 12 End

Date 13 Requested

Day 13 Start

Day 13 End

Date 14 Requested

Day 14 Start

Day 14 End

Do you need to schedule more than two weeks in advance? *

Yes

THIRD WEEK SCHEDULING INFORMATION

Date 15 Requested

Day 15 Start

Day 15 End

Date 16 Requested

Day 16 Start

Day 16 End

Date 17 Requested

Day 17 Start

Day 17 End

Date 18 Requested

Day 18 Start

Day 18 End

Date 19 Requested

Day 19 Start

Day 19 End

Date 20 Requested

Day 20 Start

Day 20 End

Date 21 Requested

Day 21 Start

Day 21 End

Do you need to schedule more than three weeks in advance?

Yes

FOURTH WEEK SCHEDULING INFORMATION

Day 22

Day 22 Start

Day 22 End

Day 23

Day 23 Start

Day 23 End

Day 24

Day 24 Start

Day 24 End

Day 25

Day 25 Start

Day 25 End

Day 26

Day 26 Start

Day 26 End

Day 27

Day 27 Start

Day 27 End

Day 28

Day 28 Start

Day 28 End

Day 29

Day 29 Start

Day 29 End

Day 30

Day 30 Start

Day 30 End

Day 31

Day 31 Start

Day 31 End

BILLING

Billing Authorization *

Billing Authorization

I hereby authorize Family Care Options by filling out and signing this credit card authorization form to charge the credit card provided for any and all services rendered and/or ordered by Family Care Options, Inc. The credit card provided will be charged in such a manner as if I were paying in person and signing a transaction slip. I understand there will be a 4% service fee for all phone and internet credit card orders.

Transportation Policy: Client is responsible for return car transportation after 10pm

Cancellation Policy:

If cancellation is not received by the agency within 24 hours of the start time of reservation the client will be charged for the entire confirmed reservation.

Method of Payment:

All major credit cards accepted and due upon confirming the care.

Name of Card Holder *

Billing Address

Billing City

Billing State

Billing Zip *

Credit Card Type *

Credit Card Number *

CVV *

Expiration Date *

Authorized Signature of Card Holder *

Clear

Our Promise To You

Personalize Service Your Way

Unlock a world of personalized care possibilities. At Family Care Options, we unveil a vibrant tapestry of professional caregivers, woven to precisely fit your family's unique needs and aspirations. Experience seamless support, crafted with compassion and expertise, to create a harmonious care journey for your loved one.

100% Happiness Guarantee

Happiness Delivered: We strive to exceed your expectations with every interaction. But if there's ever room for improvement, our 100% Happiness Guarantee ensures we'll keep working until you're completely satisfied.

Trusted Quality Service

Elevating the Standard of Care: Every member of our care specialist team is trained to the highest standards, ensuring you receive personalized service worthy of your trust.

Contact Us

1(212) 748-8377

info@familycareoption.com

142 West 57th Street New York, N.Y. 10019

Office Hours

Monday-Saturday 8:00am-8:00pm

Service Hours

24 hours/seven days a week

Office Closed

Christmas
Christmas Eve
New Years
NewYears Eve
Thanksgiving
4th of July
Memorial Day
Labor Day

Corporate Backup Care

Please fill out the form below

For Corporate Backup Care Service Request

Our Promise To You

Personalize Service Your Way

Contact Us

info@familycareoption.com

142 West 57th Street New York, N.Y. 10019

Office Hours

Monday-Saturday 8:00am-8:00pm

Service Hours

24 hours/seven days a week

Office Closed

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