Client Signature Date Sample Clauses
Client Signature Date. T2.1.20 EVALUATION SCHEDULE: REPORT ON CONTRACTOR’S COMPETANCE & PERFORMANCE ON A SIMILAR PROJECT FOR TENDER RECOMMENDATION PURPOSES PROJECT NAME and SCOPE OF WORK: Principal agent:.................................................................................................................................. Client: .. ..............................................................................................................................................
Client Signature Date. (By making a purchase, you agree to have read and agree to the conditions set in this document.)
Client Signature Date. If you do not understand the effects of this agreement, consult your attorney before signing. This is a legally binding contract.
Client Signature Date. CLIENT HISTORY
Client Signature Date. Client 2 Name …………………………………………... Client Signature .............................. Date .....................
Client Signature Date. PERTINENT CLIENT INFORMATION
Client Signature Date. I acknowledge that I have been provided with a written copy of “Clients Rights and Responsibilities" as required by state law. Best at Home is committed to take every reasonable step to ensure your satisfaction and the best possible care for you or your loved one. If any problems with your care or with our employees arise, please contact our office. Our contact information (including the email address for our owner) is below. Address Email Address: Phone: We are additionally required to provide you with the contact information of the regulatory body that licenses our agency. Their contact information is below. You may contact them to verify our license or to file a complaint. All changes to the service schedule, whether the change will be ongoing or for a certain shift only, must be communicated directly to the Best at Home office. Adjusting the schedule directly with your caregiver is not permitted and will result in disciplinary action for the caregiver and could result in overtime charges to the Client. By signing below, you understand and agree to communicate all requests for schedule changes to the Best at Home office. Transportation of clients may occur in the client’s car only. Best at Home employees are not permitted to transport clients in their personal vehicles. Do you wish to allow employee caregivers of Best at Home to drive your vehicle? YES □NO At my discretion and with my permission, I will provide an automobile for the caregiver to drive to take me or my loved one to various appointments, shopping, errands, etc. as part of the services that I will be receiving from Best at Home. I agree that I have the primary responsibility for my automobile insurance and that the caregiver is covered under my insurance as an authorized driver. I agree to indemnify, hold harmless, and release the Best at Home agency from responsibility for any action in which there is damage to myself, my automobile, and/or property and/or injury to third parties or their property. I agree to notify Best at Home of any accidents or should any change related to my current and in force insurance take place.
Client Signature Date. Employee Access to Funds Authorization For what purpose will you provide these funds? How will funds be accessed?
Client Signature Date. This authorization is only valid until [fill in date], or until three months after my file is closed at the Untethered Therapy Group.
Client Signature Date. In the event that I may be incapacitated due to severe injury or death while my pet is under the care of Johnstown Pet Services, I authorize that my pet(s) be turned over to: Name: Daytime Phone: Mobile Phone: Relationship: Evening Phone: E-mail Address: Address: Client Signature Date I hereby certify that I am providing a key(s) to Johnstown Pet Services. I authorize Johnstown Pet Services to enter my home for pet sitting services, upon my request via telephone, email, or in person. I also understand that Johnstown Pet Services will retain my key(s) for use the next time services are needed. I understand that keys will not be left at my house and I will be charged a fee of $5.00 to return key(s). I release Johnstown Pet Services from any liability connected to the detainment of my house keys. My signature below indicated agreement to these terms. Client Signature Date Consultation fee $20: Key tag color: This pet sitting service agreement is made between Johnstown Pet Services and hereinafter referred to as “JPS”, and the below named Client, hereinafter referred to a “Client” for pet sitting services.