South Edmonton Registration Form

Client's Full Name

First NameLast Name

Client's Date Of Birth

MonthDayYear

Client's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client's Email

example@example.com

Client's Phone Number

Please enter a valid phone number.

Services Required.

Dementia and Alzheimer's Companionship CarePersonal Health Care Services (PSW)Homemaker Companionship Care (MealPrepertion & Light House Cleaning)Hospital Discharge ProgramCertified Senior Home Safety Specialists (Age Safely At Home)Awake Overnight Care24-Hour Around-the-ClockEnd-of-Life Care

P.O.A. Name

First NameLast Name

P.O.A. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

P.O.A. Email

example@example.com

P.O.A Phone Number

Please enter a valid phone number.

Terms of Service*

Terms of Service

Disclosure in connection with electronic communications and e-signatures&#13;&#10;Please note that by clicking continue and signing this document generated on www.idealcaregivers4u.com you agree that you have reviewed the following disclosure and consent to &#13;&#10;&#13;&#10;(i) transact business by electronic means; &#13;&#10;(ii) receive documents electronically; and &#13;&#10;(iii) use the Ideal Caregivers 4u Inc. e-signature system. &#13;&#10;&#13;&#10;You are not under an obligation to receive documents electronically or use the Ideal Caregivers 4u Inc. e-signature system. You may request to receive hard copy paper documents instead and withdraw your consent at any time by the procedure below. The field is required.&#13;&#10;&#13;&#10;Withdrawing consent&#13;&#10;You may withdraw your consent to receive electronic documents from Ideal Caregivers 4u Inc. at any time. To withdraw consent, you must notify the sending party that you wish to withdraw consent by emailing the sending party directly. Please note that after you withdraw consent, if you choose to proceed after such time and use the Ideal Caregivers 4u Inc. e-signature system, you are consenting to receive and sign documents electronically. You can withdraw consent after the time you consent to use the system by following the procedure outlined above.&#13;&#10;&#13;&#10;Scope of consent&#13;&#10;You agree to receive electronic documents and use the Ideal Caregivers 4u Inc. e-signature system with all related and identified documents provided during your relationship with the sending party. You may withdraw your consent by following the procedures described above. &#13;&#10;By clicking the Submit button, &#13;&#10;&#13;&#10;I agree to the terms of service.&#13;&#10;* By clicking SUBMIT you consent to receiving SMS messages&#13;&#10;&#13;&#10;* Messages and Data rates may apply. Message frequency will vary&#13;&#10;&#13;&#10;* Reply Help to get more assistance&#13;&#10;&#13;&#10;* Reply Stop to Opt-out of messaging&#13;&#10;&#13;&#10;Private Policy -&#13;&#10;No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.

P.O.A. Signature

Client Registration Form