Who is Client?

• This agreement is signed by:

  • Client (i.e., a person who needs care services)
  • Guardian of a person who needs care services

• Indicate a Client's full name (this is a person for whom care services are being ordered):

• Indicate the full residential address of a Client:

• Indicate the full name of a Guardian:

• Indicate the full residential address of a Guardian:

• Indicate a Client's contact email address:

• Indicate a Client's contact phone number:

• Indicate a Guardian's contact email address:

• Indicate a Guardian's contact phone number:

General Details

• Select the date on which parties sign this Agreement:

  !

  This is the date when this Caregiver Agreement becomes effective and legally binding for both parties.

• Select the state where the Client currently resides:

  Choose option Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia

  !

  The laws of a state selected as an answer to this question will apply towards this Agreement.

• Provide the full name and address of the medical facility to which the Client should be taken in the event of an emergency:

General Information

• The care services shall be provided at:

  • Client's home
  • Other facility

• Indicate the full name and address of a facility, where services shall be provided to the Client:

• Does Caregiver provide overnight stay services?

  • No
  • Yes

  !

  Overnight stay services means that the Caregiver agrees to provide overnight care and presence for the Client.

• Indicate the hour at which the Caregiver’s overnight stay shall commence:

• Indicate the hour at which the Caregiver’s overnight stay shall end:

• Indicate an hourly rate (in USD) for the overnight stay:

Description of Services

• Should a Caregiver maintain light housekeeping (e.g., doing dishes, minor cleaning)?

  • No
  • Yes

• Should a Caregiver administer any medication (e.g., antibiotics)?

  • No
  • Yes

• Describe in detail which type of medication, when, and how it should be given to a Client:

• Should a Care Provider wash, fold, and iron a Client's cloth on a regular basis?

  • No
  • Yes

• Should a Caregiver cook fresh and healthy meals and snacks for a Client?

  • No
  • Yes

• Should a Caregiver organize mails, bills and general household tasks?

  • No
  • Yes

• Should a Caregiver organize grocery shopping and meal planning for a Client?

  • No
  • Yes

Working Hours

• Services should be provided:

  • According to a fixed schedule
  • On as needed-basis
  • Other arrangement

• Describe in detail a weekly working schedule, including exact dates and times:

• Describe in detail the exact working schedule for a Caregiver:

• Select the date of the first working day for a Caregiver:

Payment Terms

• How a Caregiver should be paid for provided services?

  • A fixed fee
  • An hourly rate
  • A daily rate
  • A weekly rate

• Indicate the amount of a fixed fee (in USD):

• Indicate an hourly rate (in USD):

• Indicate a weekly rate (in USD):

• Indicate a daily rate (in USD):

• How frequently a Caregiver shall invoice for provided services?

  • Every month
  • Every week
  • Every other month

• Indicate acceptable payment methods:

Miscellaneous

• Will a Caregiver have any paid vacation or days off?

  • No
  • Yes

• Indicate the number of paid days of holidays or days off per year :

• Do you want to add a signature?

  • Yes
  • No

• Enter a Client/Guardian signature:

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