Client Intake Assessment Form

Client Intake Assessment Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Race*
Ethnicity*
Street*
City*
State*
ZIP*
Telephone*
Email*
example@example.com
Released Date*

MonthDayYear
Date
Facility*
Court Order?
Are you a Veteran?
Are you Employed?
Do you have children?
How many under 18?
Are you married?
Do you need a ride?
Do you need Vital Documentation? (Check all that apply)
What referrals do you need? (Check all that apply)*
How did you learn about this program?*
CASE MANAGER ASSIGNED:
Date

MonthDayYear
Date
Transportation Waiver of Liability
Client Name
Date of Birth

MonthDayYear
Date
I hereby authorize The National Association for the Advancement of Returning Citizens (NAARC) to provide transportation. As part of the services (e.g., medical appointments, case management, etc given by The National Association for the Advancement of Returning Citizens (NAARC

1. I hereby release, waive, discharge and covenant not to sue The National Association for the Advancement of Returning Citizens (NAARC) and its individual members, officers, or employees (hereinafter referred to as releasees) from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or any of the property belonging to me, as result of, or in any way arising out of me traveling to and or from VOA(Baltimore Halfway House) and Washington, DC area in a vehicle or vehicles owned or operated by The National Association for the Advancement of Returning Citizens (NAARC

2. I voluntarily assume full responsibility for any risks of loss.

3. I further hereby agree to indemnify and hold harmless the releasees from any loss, liability, damage, or costs due to me traveling to and or from VOA (Baltimore Halfway House) and Washington, DC area sponsored activities in a vehicle or vehicles not owned or operated by the he National Association for the Advancement of Returning Citizens (NAARC

4. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed and enforced in accordance with the laws of Washington, DC.

5. In signing this release, I acknowledge and represent that I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed.

6. I understand that this authorization is valid for one full year beyond the date below.
Client Signature

Clear
Date

MonthDayYear
Date
Authorized NAARC representative
Date

MonthDayYear
Date
Uber, Lyft, other types of paid transportation is NOT applicable
Type a question
Should be Empty:

Client Intake Assessment Form

Transportation Waiver of Liability