HelpLine-NEPA

1 (888) 829-1341 or (570) 829-1341

Help Line

Care Telephone Reassurance Intake Form

Participant's Name:
Date of Birth:
Phone Number:
Do you have an answering machine?  
Address:
City:
State:
Zip:
List of days you wish to be called:





Time(s) to be called:
Standard message:
Medication reminder:
   

Emergency contact (1)

Name:
Relationship:
Address:
City:
State:
Zip:
Telephone #:
Alternate #:
Pager #:
   

Emergency contact (2)

Name:
Relationship:
Address:
City:
State:
Zip:
Telephone #:
Alternate #:
Pager #:
   

Emergency contact (3)

Name:
Relationship:
Address:
City:
State:
Zip:
Telephone #:
Alternate #:
Pager #:
Special comments:
 

CARE HOLDHARMLESS WAIVER

Release and hold harmless, the Family Service Association of Wyoming Valley & Help Line against any claim in relation to service received through the "CARE" telephone reassurance program.

The participant acknowledges that the Family Service Association of Wyoming Valley & Help Line is providing the "CARE" service as a public service for no compensation. The participant recognizes that Help Line or Family Service Association of Wyoming Valley may in their sole discretion; terminate this service at any time.

In consideration of these factors, the participant hereby waves, releases and holds harmless the Family Service Association of Wyoming Valley & Help Line from any claim arising from a failure for any reason to provide the services contemplated by this agreement and the participant further agrees to wave, releases and holds harmless the Family Service Association of Wyoming Valley & Help Line against any claim for direct incidental or consequential damages arising from any act or omission of the Help Line and the Family Service Association of Wyoming of Valley their volunteers, agents or employees, in connection with the Help Line & Family Service Association of Wyoming Valley's participation in this program.

By checking this box (REQUIRED), I certify that I AGREE to the above CARE HOLDHARMLESS WAIVER.