I, (Parent) authorize the assigned caregiver to provide care for my child(ren) listed below in my home. I authorize the caregiver and Hennepin Home Health Care, Inc. to use whatever emergency measures are deemed necessary, at my expense, and will not hold Hennepin Home Health Care, Inc. or its employees responsible for decision that are made in good faith during my absence in time of emergency.
List all children that may be serviced:
1. Child’s name and date of birth:
2. Child’s name and date of birth:
3. Child’s name and date of birth:
Check below which one pertains to you:
I am an employee of , who has contracted with the company (“Hennepin Home Health Care, Inc.”) Employee #: and Social Security number . I understand that my company has gone into an agreement with the company and that I am responsible for the percentage that my employer is not paying. I am aware and agree to the terms of that contract.
I agree to pay the full amount of services, since I do not have a company that is willing to contract for services with the company. I agree to pay $20.00 per hour for one child and $5.00 for each additional child. I realize there is a four-hour minimum and agree to pay that full amount. I understand there is a $60.00 cancellation fee and possibly a $40.00 port-to-port fee.
All Parents, regardless of payer:
I agree to pay a sum of $2000.00 in damages to reimburse Hennepin Home Health Care, Inc. for the cost of recruiting, hiring, and training, if I directly employ any employee of the company that has provided services within six months of services.
Home Address:
City State Zip Code
Home Phone #:
Emergency Contact (other than the parent)
Name/Relationship:
Phone #:
