“Waiting to Exhale”

Family Caregiver Monthly Self-help Gatherings

**There is no fee to participate or receive the services provided, but donations of any amount are graciously accepted.

Please complete the registration form in its entirety.

Name

First Name

Last Name

Name you would prefer to be called

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Emergency Contact Name

Emergency Contact Phone

(###)

###

####

Will you require the services of a certified caregiver while attending WTE or respite?

If one is required, list the services or ADL’s (Activities of Daily Living) that will be needed.

Please understand that our CNA’s may not be able or allowed to perform certain services that you may require.

Please indicate your T-shirt size.

Please read the following statements to signify your understanding and willingness to comply with all policies associated with participating in Waiting to Exhale (WTE).

I understand that being a participant of WTE requires a high level of confidentiality and respect for all involved.

Yes

When utilizing the services of the respite home, I will abide by all house rules set forth by the homeowner and the WTE staff

Yes

I understand that any services I request outside the realm of responsibilities of a WTE staff or volunteer may incur al fee which I will be responsible for .

Yes

Do you agree to all of the above referenced policies?

Yes

Date

YYYY