Connect Card

Family Name:*
Client Email:

A copy of this information will be sent to this address. Please only enter an email if client wants to receive a copy.
Caregiver Name*
First Last Initial
Caregiver Email

A copy of this information will be sent to this address. Please leave this section blank if you do not wish to receive a copy.
Activity Log (Please check all that apply.)
- Meals/Snacks Given
- Diaper Changes/Potty Time(s)
- Sleep/Rest
- Medication Administered (Authorization Required)
Please list meal/snack times, description and notes:
Please list diaper change/potty times and any notes:
Please list sleep or rest times/duration and notes :
Please list medications administered, dosage, times and any notes:
Look what we did today!*
Oops! We had an accident!
Wow! Something exciting happened!
Additional Care Notes:
Receipt
To be filled out by caregiver and signed by family.
Shift Start Time*

: Hours

Minutes

AM/PM
Shift End Time*

: Hours

Minutes

AM/PM
Care Type*
Additional Children?
- 3 Children
- 4 Children
- 5 Children
Mileage

Specify total number of miles driven for on-the-job driving.
Expense Reimbursement
Please list any out-of-pocket costs during your shift.
- Client Present to Sign
- Client NOT Present to Sign
Signature
I understand and agree to the charges outlined on this receipt.
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Receipt