Care Premium Enrollment

Please fill out the following information so that we may process your order. When each page is completed press the 'submit' button to send the information to us. If you would like to be contacted by our office regarding any of the information needed, please place a note to that effect in the comment box at the end.

Please provide the following information for the parent that is to be our primary contact:

First Name		Last Name
Street Address		City
State		Zip Code
N/S Cross Street		E/W Cross Street
Home Phone		Home Fax
Employer		Work Phone
Work Fax
Driver's License #
E-mail (cannot be blank, use a 'dummy' address if necessary)

Please provide the following contact information for your spouse (if applicable):

First Name		Last Name
Employer		Work Phone
Fax		E-mail

Please provide the following payment information. We use only a secured server to process your payment information. However, if you prefer, you may enter a number here of '999999999' and then call, email or fax (480-460-1200) our office with your billing information.

	BILLING
Cardholder Name
Card Number
Card Type		Expiration

Choose one of the following options for us to send profiles and information to you:

Your credit card will be charged today for the deposit amount listed below:
CarePremium non-refundable deposit: $300.00 - there is NOT a separate registration or application fee.

Please tell us how you heard about Parent's Time-Out:

Name of Nanny, Friend, Co-worker, etc. Referral(s):

To review the Client Terms and Conditions for CarePremium

I understand and accept the Client Terms and Conditions

Check our company’s
ratings at Angie’s List.

(480) 460-1200
Fax: (480) 460-1200
Email Us!

We are proud to be members of the following professional organizations:

International Nanny Association (INA)
National Association of Nannies (NAN)
Better Business Bureau
National Association for the
Education of Young Children (NAEYC)
Arizona Association for the Gifted and Talented

Privacy Statement: We will NOT share your information with ANYONE!

Created by: Access by Design,
1999-2007

[HOME] [FOR PARENTS] [SEARCH THE DATABASE] [ENROLL IN PROGRAMS] [FOR APPLICANTS] [CONTACT US]