Client Pairing Questionnaire Question Title * 1. Name Question Title * 2. Client Name Question Title * 3. Client Age 0-5 6-10 11-18 18+ Question Title * 4. Client Gender Question Title * 5. Do you have a preference for provider gender? Male Female No Preference Question Title * 6. During what days are you in need of a provider? Please choose all that apply AM PM ALL DAY Monday Monday AM Monday PM Monday ALL DAY Tuesday Tuesday AM Tuesday PM Tuesday ALL DAY Wednesday Wednesday AM Wednesday PM Wednesday ALL DAY Thursday Thursday AM Thursday PM Thursday ALL DAY Friday Friday AM Friday PM Friday ALL DAY Saturday Saturday AM Saturday PM Saturday ALL DAY Sunday Sunday AM Sunday PM Sunday ALL DAY Question Title * 7. Does your child have allergies or health issues that would prevent certain providers from coming into your home? YES NO If yes please specify Question Title * 8. Do you have any pets? YES NO If yes please specify Question Title * 9. Check the activities you and your family enjoy doing? Biking Running Football Roller Skating Hockey Soccer Swimming Tennis Track and Field Hiking Frisbee Ballet Baseball Exercise Walking Golf Mini Golf Gymnastics Karate Paintball Skiing Sledding Fishing Bowling Hopscotch Museums Gardening Reading Crafting If others please specify Question Title * 10. Do you have cultural preferences that would prevent you from having a provider working in your home? (Optional) YES NO If yes please specify Question Title * 11. Do you have religious preferences that would prevent you from having a provider working in your home? (Optional) YES NO If yes please specify Done