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Caregiver Application

 
We select individuals who have been in an unpaid caregiving role for a chronically ill individual, elder or disabled person for 12 months or longer. In order to qualify, applicants must not have an annual income exceeding $80,000.
 
Nomination
Are you nominating a Caregiver?

 
 
Required Caregiver Information
 
 
 
 
 
 
 
 
 
How is the Caregiver coping with being a care provider?
 
 
Required Care Receiver Information
 
 
 
 
 
 
How long has the Care Recipient been receiving care?
 
 
Additional Information
Additional information is used to help understand how the Caregiver Relief Fund can best assist you.

Would you like to provide additional information?

 
 
Waiver and Release from Liability
 

For and in consideration of receiving a referral for home nursing care at no cost, I (also, the “Undersigned”), HEREBY RELINQUISH, WAIVE AND RELEASE, indemnify, hold harmless and forever discharge Caregiver Relief Fund Inc. (“CRF”) and its agents, employees, officers, directors, affiliates, members, representatives and assigns (collectively with CRF, the “Released Parties”), of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages, losses and liabilities, of every kind and nature, whether known or unknown, in law or equity, that I ever had or may have, arising from or in any way related to the in home nursing care being provided to me by a third party (the “Service Provider”) referred by CRF (“Claims”), provided that this waiver of liability does not apply to any intentional, willful or wanton misconduct by the Released Parties. Further, the Undersigned COVENANTS NOT TO SUE any Released Party with respect to any such Claim.

I understand that the health related assistance being provided to me by the Service Provider may be inherently dangerous and can cause serious or grievous injuries, including bodily injury, damage to personal property and/or death. On behalf of myself, my heirs, next of kin, executors, personal representatives, administrators and assigns, I relinquish and waive all Claims for damages, injuries and death sustained by me or my property that I may have against any aforementioned Released Party.

By this WAIVER AND RELEASE, I assume any risk, and take full responsibility and relinquish and waive any Claims of personal injury, death or damage to personal property associated with the services provided by the Service Provider referred by CRF, including but not limited to receiving home health care assistance, using any of the equipment in any manner, form or fashion, or engaging in any medical care or rehabilitative therapy from the attending nurse or assistants.

This WAIVER AND RELEASE contains the entire agreement between the parties, and supersedes any prior written or oral agreements between them concerning the subject matter of this WAIVER AND RELEASE. The provisions of this WAIVER AND RELEASE may be waived, altered, amended or repealed, in whole or in part, only upon the prior written consent of the Undersigned and CRF.

The provision of this WAIVER AND RELEASE will continue in full force and effect even after the termination of the activities conducted by, on the premises of, or for the benefit of the Undersigned, whether by agreement, by operation of law, or otherwise.

I have read, understand and fully agree to the terms of this WAIVER AND RELEASE. I understand and confirm that by signing this WAIVER AND RELEASE I have given up considerable future legal rights. I have signed this Agreement freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to me. My signature is proof of my intention to execute a complete and unconditional WAIVER AND RELEASE of all liability to the full extent of the law. I am 18 years of age or older and mentally competent to enter into this waiver.

IMPORTANT - BY CLICKING ON THE “SUBMIT” BUTTON BELOW, YOU INDICATE THAT YOU HAVE READ, UNDERSTAND, ACCEPT AND CONSENT TO BE BOUND BY THIS WAIVER AND RELEASE.

 

 
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