Client Service Agreement

1. This program is designed to be self-directed. Care Recipients and/or Caregivers can determine which services are needed and are responsible for managing financial assistance.

2. The financial assistance expires at the end of each program year. If you do not think that you will use the total amount of your assistance, please contact your case manager! Otherwise, this money will go unspent.

3. Care recipients must be living in the community (i.e. house, apartment, etc) and not in a facility (i.e. assisted living, nursing home).

4. Re-assessments are conducted annually for all program participants.

5. The program is meant to provide case management and supplemental assistance to care recipient and/or caregiving needs and is not able to provide full support for long-term care needs.

6. JF&CS reserves the right to suspend or terminate Supportive Services Program services for suspected misuse or improper use of financial assistance. Referrals to other care recipient and/or caregiver support and services will be provided in the case of termination.

As a client in the program, you must agree to the following:

1. I am currently caring for a family member / am a care recipient living in the community. If my status as a care recipient changes / if my caregiver status changes and/or my family member moves to an assisted living facility or nursing home, I will inform my case manager. I will also inform my case manager myself or my family member goes into the hospital or a rehabilitation facility for any length of time.

2. I am willing to manage the support program and will contact my case manager with any questions / concerns

3. I am not currently active in any other subsidized caregiver programs, such as Medicaid's Community Care Support Program (CCSP), Source, Support Options, or other subsidized home care or state-funded respite care programs.

4. I agree to inform my case manager immediately if I do apply for, or enroll in, another program and understand that this may affect my status in the JF&CS Support Services Programs.

5. I release JF&CS to speak with all service providers that I utilize as a part of the Supportive Services Program

6.I will participate in reassessments, satisfaction surveys and other data collection tools needed for this program and for the funders of the JF&CS Supportive Services Program.

I agree to the above guidelines and my case manager has reviewed this Client Service Agreement

Waiver and Release from Liability

I have requested participation in the Caregiver Support Program offered by Jewish Family & Career Services (JF&CS). As a condition of being granted permission to participate in the Program, I agree to release, indemnify, and hold harmless JF&CS, its principals, officers, successors, assigns, staff, employees, and other related entities from any and all claims, liabilities, losses and causes of action arising from or related to participation in the Caregiver Support Program.

By this Waiver, I assume any risk, and take full responsibility and waive any claims of personal injury or death, or damage to or loss of personal property associated with participation in the Caregiver Support Program, arising out of or caused by the negligence, in whole or in part, of JF&CS or any other party.