iCare Client Application

735 Sycamore Drive, Decatur, GA 30030

Office: 404.377.2273
Client Application Form
Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

City

CountyState

Postal / Zip Code
Phone number (Home)
Phone Number (Cell)
Email address
example@example.com
Where did you hear about I CARE
Emergency Contact Name
First & Last Name
Emergency Contact Phone Number
Please provide the name and phone number of one reference (someone not related to you):
Reference Name
First & Last Name
Reference Phone Number
Do you use the assistance of any of the following?

CaneWalkerWheelchair (We can only accommodate foldable wheelchairs.)Other
Are you eligible for MEDICAID

YesNo
Are you eligible for Para Transit Marta Mobility

YesNo
What is your reason for applying for I CARE service
Ethnicity (Optional)
Please acknowledge receipt of this document and the attached guidelines, with your signature and date below:
Client Signature

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Date

MonthDayYear
Date

Client Agreement and Release
In exchange for I Care, Inc.'s ("I Care") agreement to accept the individual named below as a client ("Client"), Client freely and voluntarily agrees to the following Release and Waiver of Liability ("Release") for and on behalf of him or herself and his or her heirs:

1. Waiver and Release of Legal Claims and Assumption of Risk.

a. As a client of I Care, Client may participate in activities at I Care that include but are not limited to entering or exiting the personal vehicles of I Care volunteers or staff, and travel to and from Client's residence to medical appointments, grocery stores or pharmacies in those personal vehicles. These I Care activities may be strenuous or stressful.

b.Client understands that such activities - as well as potential exposure to COVID-19 during such activities - may be hazardous to Client. Client assumes the risk of any such hazard.

c.Client releases and indemnifies I Care and its directors, officers, employees, volunteers, agents, successors and assigns (collectively, the "Released Parties") from any and all liability, loss, cost or expense related to I Care activities or to any illness (including but not limited to COVID-19), injury, death, or property loss or damage related to the activities.

d. Client also understands that the Released Parties do not provide any financial assistance of any kind, including but not limited to medical, health or disability insurance coverage for any client of I Care.

2. Medical Treatment. Client releases and indemnifies the Released Parties from any and all liability, loss, cost or expense arising out of or relating to any first aid or medical treatment rendered in connection with I Care activities.

3. Notification of Accident or Injury. Client agrees promptly to notify I Care of any accidents or injuries that occur during I Care activities, and to cooperate and provide all necessary related information to I Care.

4. Media Release. Client transfers to I Care all right, title and interest in any photographic images and video or audio recordings made by or for I Care during Client's participation in I Care activities, including, but not limited to, any payments or other benefits from such photographs or recordings.

5. Governing Law. Client expressly agrees that this Release is intended to be as broad and inclusive as permitted by the laws of the state of Georgia, and that this Release will be governed by and interpreted in accordance with the laws of the state of Georgia. Client agrees that in the event that any portion of this Release is held to be invalid by any court of competent jurisdiction, the invalidity of that portion will not affect the remaining provisions of this Release, which will continue to be enforceable. Client agrees that the sole and exclusive jurisdiction and venue for litigation between Client and I Care will be a state or federal court having jurisdiction over Dekalb County, Georgia.

I HAVE READ AND UNDERSTAND THIS RELEASE AND WAIVER OF LIABILITY, AND I UNDERSTAND THAT I AM GIVING UP SPECIFIC LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE THE RELEASED PARTIES, BY SIGNING THIS AGREEMENT.
Signature

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Name
Date

MonthDayYear
Date
Should be Empty:

Client Application Form

Client Agreement and Release