Non-member Care Waiver

WE ARE DELIGHTED TO SERVE YOUR FAMILY!

Parent/Guardian 1 Name:(Required)

Parent/Guardian 1 Contact Number:(Required)

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Parent/Guardian 1 Contact Number:

Parent/Guardian 2 Name:

Parent/Guardian 2 Contact Number:(Required)

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Parent/Guardian 2 Contact Number:

Child(ren)'s Name(s):(Required)

Doing a Nanny Share?

Please list the family name that is participating in the nanny share with you.

Emergency Contact Name:(Required)

Should be someone other than parent/guardians listed above.

Emergency Contact Phone(Required)

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Emergency Contact Phone

I would like to receive additional information about Trusting Connections Nanny Agency services.(Required)

Yes

Care Waiver

PLEASE INITIAL BELOW: I hereby permit Trusting Connections, LLC to provide care to my child(ren) and agree, in taking advantage of this child care service, to release and hold harmless Trusting Connections, LLC, its officers, trustees, agents, and employees, from any and all claims, demands, suits, costs and charges, in connections with or arising out of the child care service, including, but not limited to, bodily harm or injury to my child(ren), except only for loss, harms or injury occasioned by gross negligence or intentional misconduct by a Trusting Connections nanny. In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize the Trusting Connections nanny or person in charge to engage emergency services to provide necessary medical treatment. I further understand that Trusting Connections caregivers do not administer medication or drive children in their care without written permission to do so. Client understands and agrees that, to the maximum extent allowed by law, all information and materials about Caregivers are to be kept strictly confidential and are to be used only in conjunction with TC’s childcare services. If family solicits, hires or otherwise engages an agency employee or provides employee information to another party and the other party hires or otherwise engages the Candidate without compensating TC its full placement fees, family will be responsible for paying TC’s full placement fees as if TC had placed the Candidate with a client. TC does not use or distribute personal family information for purposes not directly necessary for providing proper services. Caregivers are prohibited from discussing personal matters about a Client, the Family or the child or person in the Caregiver’s care with individuals outside of the Agency. Notwithstanding the foregoing, in the case of abuse or neglect of a minor or a vulnerable adult, TC and its staff reserves the right to report suspicions of abuse to authorities.(Required)

I have read, understood and agree to the terms and conditions outlined in the above Care Waiver.(Required)

Yes I accept.

No, I do not accept.

Name(Required)

Signature(Required)

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Date:

Date(Required)

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WE ARE DELIGHTED TO SERVE YOUR FAMILY!

Care Waiver

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