Senior Application For Membershi

Senior Application For Membership
**NEW
You must be at least 70 years old

Please complete the below application

Name	First	Middle	Last
Mailing Address	Street	City	State ZIP
Phone	Home: (Numbers only)	Date of Birth:	Age of Senior?
Do you have any special needs. ie. wheelchair/walker: How are you getting around now? Is it difficult for you to get around by yourself? Do you need assistance when you are on an outing? Do you have someone now that can provide you assistance when you are on an outing?	Yes No No Yes No Yes No Yes If yes, who?

4)How did you hear of us?

5) How can we assist you? We don't do any house cleaning.

In case of emergency please notify:

Name	First	Middle	Last
Mailing Address	Street	City	State ZIP
Phone	Home:	Business:	Mobile:
Relationship

By completing this application the Senior agrees to indemnify and hold Daughter For The Day, Inc., and its officers, directors, associates and staff harmless from any and all actions, claims, damages, or liabilities arising from any services provided to the Senior, or arising out of, or in connection with any breach of this agreement by Daughter For The Day, Inc.