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:ReceiptTo be filled out by caregiver and signed by family. Shift Start Time* : Hours Minutes AM PM AM/PM Shift End Time* : Hours Minutes AM PM AM/PM Care Type*TC CareQuick TC CareInfant CareQuick Infant CareOvernight Infant CareIn-Home EducatorFamily AssistantResort CareCorporate CareAdditional Children? 3 Children 4 Children 5 Children Mileage Specify total number of miles driven for on-the-job driving. Expense ReimbursementPlease list any out-of-pocket costs during your shift. Client Present to Sign Client NOT Present to Sign SignatureI understand and agree to the charges outlined on this receipt. CAPTCHA