Adult Care Provider Signup

Primary Coverage Area Zip Code(s)* :: Seperate multiple zip codes by a comma (,)
Service Area Within* :: If you operate a franchise please select as primary zip code.
Description of Services Offered*
Total Number of Local Caregiver Hours Donated
Max Number of Hours to be Granted per Recipient
Please include the following attachments with application*
Please Initial*
Please initial :: Indemnitor: Provide Your Initials
Waiver and Release from Liability

For and in consideration of the care provider that clicks the Submit button below (the Undersigned) receiving recognition for donating home nursing care at no cost, the Undersigned HEREBY RELINQUISHES, WAIVES AND RELEASES, indemnifies, holds harmless and forever discharges 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 the Undersigned ever had or may have, arising from or in any way related to the in home nursing care being provided by the Undersigned (or its agents) to a third party individual (the Patient) 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.

The Undersigned understands that the health related assistance being provided by it to the Patient may be inherently dangerous and can cause serious or grievous injuries, including bodily injury, damage to personal property and/or death of the Patient. On behalf of itself, its officers, directors, shareholders/members and assigns, the Undersigned relinquishes and waives all Claims related to any damages, injuries and/or death sustained by the Patient or his or her property that the Undersigned may have against any aforementioned Released Party.

By this WAIVER AND RELEASE, the Undersigned assumes any risk, and takes full responsibility and relinquishes and waives any Claims related to personal injury, death or damage to personal property associated with the services provided by the Undersigned, including but not limited to providing home health care assistance, using any of the equipment in any manner, form or fashion, or engaging in any medical care or rehabilitative therapy.

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 the Undersigned, whether by agreement, by operation of law, or otherwise.

The Undersigned has read, understands and fully agrees to the terms of this WAIVER AND RELEASE. The Undersigned understands and confirms that by signing this WAIVER AND RELEASE, it has given up considerable future legal rights. The Undersigned has signed this Agreement freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to it. An authorized signature of the Undersigned is proof of its intention to execute a complete and unconditional WAIVER AND RELEASE of all liability to the full extent of the law.


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