Form

Backup Care Request

Tell us about yourself:

Employee First Name*

Employee Last Name*

Work Email*

Phone Number*

Company*

Second Parent/Guardian First Name

Second Parent/Guardian Last Name

Second Parent/Guardian Company

Where do you need care?

In Home Child Care:
Please provide the address where you need in home care (i.e. your home address, or a hotel if you are traveling for business with your child(ren))

Center Based Child Care:
Please provide the address(es) closest to where you would like to find childcare. For example, the primary address may be your home address, and secondary address may be your office if you are commuting to the office.

Primary Street Address*

Primary City*

Primary State*

Primary Zip Code*

Example: 10013

Primary Country/Region

Secondary Street Address

Secondary City

Secondary State

Secondary Zip Code

Example: 10013

Secondary Country

Who needs care?

Child 1 First Name*

Child 1 Birthdate*

Month/Day/Year

Child 2 First Name

Child 2 Birthdate

Month/Day/Year

Child 3 First Name

Child 3 Birthdate

Month/Day/Year

What type of care do you need?

Childcare Options*

In Home Child Care (All Ages)

Center Based Child Care (Ages 0-5)

When do you need care?

Note: If your care request is more than four weeks in advance, we will be unable to confirm care until four weeks prior to the date requested.

Date 1*

Month/Day/Year

Care Start Time 1*

Care End Time 1*

Time Zone 1*

Date 2

Month/Day/Year

Care Start Time 2

Care End Time 2

Time Zone 2

Day 3

Month/Day/Year

Care Start Time 3

Care End Time 3

Time Zone 3

Day 4

Month/Day/Year

Care Start Time 4

Care End Time 4

Time Zone 4

Day 5

Month/Day/Year

Care Start Time 5

Care End Time 5

Time Zone 5

If a colleague referred you to Vivvi, please share their name below!

Is there anything else we should know?

I understand that I can only use backup care for work-related purposes.*

Health and Safety Protocols*

Vivvi Backup Care cannot be provided for an individual experiencing contagious illness (i.e. COVID-19) or symptoms of fever (100.4 or higher), vomiting or diarrhea.

At this time, my child is not experiencing any illness or symptoms that would prevent Vivvi from booking backup care.

If my child becomes ill prior to the booking, I will contact Vivvi at backup@vivvi.com.

Backup Care Request

Tell us about yourself:

Where do you need care?

Who needs care?

What type of care do you need?

When do you need care?Note: If your care request is more than four weeks in advance, we will be unable to confirm care until four weeks prior to the date requested.

When do you need care?

Note: If your care request is more than four weeks in advance, we will be unable to confirm care until four weeks prior to the date requested.