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Nanny_Referral_Application_Form.3155454

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					  30-81 Steinway Street, Astoria, N.Y 11103 / Ph: (718) 278-1570 / www.dikidaycare.com



               Nanny Referral Request Form
Date_____________

Parent(s) Name(s) _______________________________________________________

Parent(s) Occupation(s)___________________________________________________

Address________________________________________________________________

City_____________________________ State _________ Zip_____________________

Home Phone________________________ Email_______________________________

Child(s) Name(s) & Birth Date(s) ___________________________________________

Any Special Needs or Allergies_____________________________________________

Live In, Full Time or Part Time_____________________________________________



English fluency level required (extremely, medium, conversational, minimum)
_______________________________________________________________________

Describe type of service you would like for your household _______________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Please remit a one time referral fee of $300 dollars payable to Diki Day Care. This
referral fee is valid for one year from the application date.


______________________________                             ________________________
Name                                                       Date



_______________________________
Signature