KymberCare Overnight Pet Sitting Agreement & Authorization & Request Form

1
Client’s Full Name* This field is required.
First Name
Last Name
2
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Client’s Phone Number* This field is required.
4
Address of where will you be staying or can be reached?* This field is required.In case of emergency.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Phone Number of where you will be staying in case of emergency.
Please enter a valid phone number.
6
Emergency Contact Name * This field is required.
First Name
Last Name
7
Emergency Contact Number * This field is required.
8
Additional Emergency Contact Name
First Name
Last Name
9
Additional Emergency Contact Number
10
Vet Name * This field is required.
First Name
Last Name
11
Vet Contact Number * This field is required.
12
WiFi Information * This field is required.
13
TV information (type, how to control it) this can be reviewed in person or general instructions left here* This field is required.
14
Start Date For Services* This field is required.
Date
Month
Day
Year
15
What time will you be leaving?* This field is required.
16
End Date For Services * This field is required.
Date
Month
Day
Year
17
What time will you be returning?* This field is required.
18
How will services be paid for. (This selection can be changed with sitter agreement ) -Payment is due no later than 48hrs after the last service day (Unless otherwise arranged) -Late payments will incur a $5 charge per week late. -Rebooking after a late payment will require payment deposit of 50% of service that is due at time of booking with the remainder due prior to the first night of service. -Failure to pay for services will result in an automatic ban from rebooking.* This field is required.* This can be changed if needed
Venmo ~ @Kymber-Lauritzen
CashApp ~ $KymberLauritzen
Paypal ~ @Kymberlauritzen
Cash
Check
Apple Pay ~ 260-336-3919
Facebook Pay ~ Kymber Lauritzen
Zelle ~ Kymber Lauritzen or 260-336-3919
Other
19
How Many Animals * This field is required.
20
Breed(s) of Animals * This field is required.
21
Animal Names & Ages* This field is required.
22
Feeding Schedule * This field is required.
23
Can the animals be left alone during the day?* This field is required.
Yes
No
24
Animal Biting History (if applicable - type N/A if not)* This field is required.
25
Information about the animals daily routine* This field is required.
26
Animal Allergies* This field is required.
Yes
No
27
What are the Allergies?
28
Medications* This field is required.
Yes
No
29
Medication name, dosage and frequency
30
Where will food be stored and location of bowls?* This field is required.
31
Where will the animals stay while sitter is away?* This field is required.
32
Where will the animals sleep at night?* This field is required.
33
Outside information
Wireless Fence
Stay in the yard
Physical Fence
Leashed
Tie outs
Does not apply to my home
34
-I do work a full time hospital job 8-4:30p that is M-F as well as 1 weekend a month 9-5:30p in Fort Wayne. -I occasionally pick up other hours at the full time job but this rare. Would this be a problem?* This field is required.
Yes I’m fine with this
Maybe
Need more information on specifics
No - this won’t work
Other
35
Will the Sitter have flexibility to come & go during evenings and weekends on occasion? * This field is required.
YESNO
36
Do you have Cameras?* This field is required.Any of the below items that are not properly disclosed could result in the termination of contract and forfeiture deposit.
Camera’s in the Home
Camera’s Outside the home
37
Camera Location & Functionality * This field is required.Are they Video/Audio etc……Any of the below items that are not properly disclosed could result in the termination of contract and forfeiture deposit.
Huge
Large
Normal
Small
Ok
Ok
38
Other Security Measures that the sitter needs to be aware of.* This field is required.
Alarms
Key code Entry
Other
39
How will the sitter enter the Home? (Key Code, Alarm Code, where will key be left etc) * This field is required.
Security Info
40
Additional Information not included in form.
41
Pet Sitting Agreement/Authorization -I authorize the pet sitter (Kymber Lauritzen) to watch my animals in my home while I am away for dates and services stated above. - I agree that payment will be made no later than 48hrs from the last service date. -I also authorize the pet sitter (Kymber Lauritzen) to act as my agent in the event of my animal(s) needing medical attention. -I further agree that I will be responsible for any and all costs of any veterinary care deemed necessary by the licensed veterinarian. -I have read the above terms and conditions. I know, understand and agree to all terms stated above. -I verify that all the above information is filled out and factual as possible. -I have agreed to the payment selection, amount and terms. -I the undersigned further understand that I the client hereby assume all risk and liability that may result in using KymberCare services. -I agree to release, indemnify, defend, and forever discharge Kymber Lauritzen from all liability, claims, demands, damages, costs, expenses, and causes of action due to death, injury, loss, or damage to the undersigned. -By selecting “I AGREE” you are accepting this document as a contractual agreement.* This field is required.
I AGREE
42
Signature or Initials* This field is required.
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43
Date* This field is required.
Date
Month
Day
Year
Should be Empty: