Application for Temporary Elder Care Services

Please fill out the form below

Client's Name
Client's Representativee (if applicable) Phone
Email Address Fax
 
Client's Information:
Home Address: City Zip
Home Phone: Email Address:
Fax
Who should we contact?
 
Client's Limitations:
Hearing   Speech   Vision   Mobility   Swallowing
Breathing   Cognition   Performing Activities of Daily Living
 
Does the client have any medical conditions?
Special diet and /or nutritional needs:
Allergies:  None  Yes
(Specify)
Referred by (i.e. self, friend, family, etc.):
Please note any special needs:
Other members of household (relatives, domestic help, older siblings etc.)
Name Age Relationship to client
Name Age Relationship to client
Do any members of household smoke?
Pets(please list)
Please tell us about your temporary care needs
 
Caregiver Characteristics: Please list important qualities you feel the companion should possess.
Caregiver Responsibilities: Please list companion's duties regarding your client.
Housekeeping Duties: Please list the housekeeping duties you will require (no heavy cleaning, shoveling).
Family Information: Please list any information about your family that may help us in making a successful placement.
Please describe what you feel to be the ideal working relationship between your family and your companion.
How were you referred to Babies to Boomers?
Are you currently working with any other agencies to find a companion? If yes, please list
 
The Babies to Boomers Temporary Services Client Understanding and Release:
Understanding between parties:
  1. Babies to Boomers agrees to make its best effort to locate temporary caregivers for client's care needs on an as requested basis.
  2. Client agrees to pay caregivers directly for services rendered. Typically this falls in the $15-$25 range. Rate should be discussed with the care provider prior to care. There is a 4 hour minimum for services.
  3. Client understands that an agency fee will be charged to their credit card for every confirmed reservation.
  4. Client understands that if s/he cancels a caregiver who has already been confirmed by Babies to Boomers s/he will be charged the agency reservation fee. Client further understands that if canceling with less than 48-hour notice, s/he will be charged the four-hour minimum for the caregiver in addition to the agency reservation fee. If holiday reservations are made and canceled the 4 hour minimum will be charged and paid to the caregiver.
  5. Client understands that the services provided by all caregivers referred by Babies to Boomers must be contracted through the Babies to Boomers office. Client further understands that the use of a Babies to Boomers caregiver, or referral of a Babies to Boomers caregiver to a third party, without arranging the visit through the agency, is considered “theft of services” and will result in a charge of $1000 for liquidated damages.
  6. In the event that Client wishes to hire a Caregiver referred by Babies to Boomers on a permanent basis, Babies to Boomers agrees to negotiate with the client in arriving at an acceptable placement fee.
  7. Client understands that caregivers working with Babies to Boomers are not employees of Babies to Boomers. Client understands that if they pay more than $1,700 per calendar year to any one caregiver they are responsible for withholding and filing employment taxes for that person. Social Security number of caregivers must be obtained directly from caregivers.
  8. Client agrees to forever indemnify, release and hold harmless Babies to Boomers, its agents, employees, and officers for any and all claims relating to services provided by caregivers.
  9. Client understands that a companion is a non-medical caregiver and that they may not administer medication of any kind or perform nursing services. However, in an emergency when medication or a nursing procedure must be performed when no qualified person is available, you will hold harmless Babies to Boomers, its agents, employees, and officers for any harm that may come to the client as a result of the companion's actions.
  10. The client is responsible for any expenses associated with household supplies, personal supplies, and for companions meals while they are engaged with the client.
 
I have read and understand the terms of this agreement
I Agree
I disagree
 
Transportation Waiver: (optional)
I , hereby give consent for a Babies to Boomers caregiver to transport client in her or my automobile. I understand that caregivers with Babies to Boomers are not employees of Babies to Boomers. Babies to Boomers is in no way responsible for the safety of the client while being transported in caregivers or our family's automobile. I agree to forever indemnify, release and hold harmless Babies to Boomers, its agents, employees and officers for any and all claims including injury to client's car or client while being transported by a Babies to Boomers caregiver.
 
I understand and agree to the above transportation waiver
I do not agree to the above transportation waiver
 
Client Signature Date
 
 
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