Course Registration Form

Registration Form

Fill out the form carefully for registration
Your Name

First NameLastPhone Number
Client's Name

First NameLastPhone Number
Client's DOB

MonthDayYear
Gender
Name client prefers to be called
Favorite color
Favorite animal
Favorite movie
Favorite sit down activity
Favorite snack/candy/dessert
Tell us a little about your loved one!!!!
Email
example@example.com
Laundry pick up/Companionship Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
My Services
prevnext( X )
Laundry Service + Companionship Laundry will be picked up and 2 hours of Companionship with be spent with client laundry will be returned in 2 days time and an additional 2 hours of Companionship will be spent with the client laundry will be folded and put away neatly.
$150.00 Quantity



Laundry ServiceClothing will be picked up washed and returned in 2 days time neatly folded and put away for client
$100.00 Quantity



Companionship 2 hours of Companionship. An additional 2 hours can be added to the same seesion for a discounted price. See below
$75.00 Quantity



Companionship add-onAdditional 2 hours of Companionship added to either companionship+laundry or companionship only options. This option can be added to either pick up day or drop off day.
$60.00 Quantity



CNA ServicesWill your loved one need CNA services performed during their companionship session.THIS IS NOT A PROBLEM!!! I have been certified for 15 years and have no problem with performing these duties. Call to inquire more!
$50.00 Quantity



Total

$0.00
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