Client Form

For Short-Term Care, Long-Term Care, and Background Check services fill out the application below on this page. We will follow up with you shortly.Taking the time to fully understand our client’s needs is what makes our placement process so successful. Before you begin working with us we ask that you fill out the application below. It details all of the specific requests you may have for your family’s specific situation and will help us make a placement or help us help you make a decision that is an appropriate choice. We are dedicated to making sure that you are completely happy with the process and the end result.The form below is not only a needs assessment, it specifies what you can expect from us as a client and is a contract defining our terms of service. We look forward to being an extension of your family and helping to make your life easier. Please call our office any time if you need additional assistance or simply would rather discuss by telephone at 877-553-4231, ext. 1.

You will be prompted to fill out billing information after this form is completed on the submission page. To complete the process you must fill out our secure billing collection form.

Short-Term Care, Long-Term Care, and Due Diligence Services Application

Service Location*
Type of Care
Please select services you will be utilizing*
- Short Term Back Up Child Care Pay As You Go Full Employment (4 hour minimum)
- Private Educator via Pay As You Go Full Employment (4 hour minimum)
- Long Term Placement Referral
- Due Diligence
- Errand Running
Rates*
- This is a required field regardless of which service you utilize. You will not be charged unless we fill and confirm a temporary case. You will not be charged for a Long Term Search unless you select that option above and you have gone through the placement process. We ask all clients to fill out our agreements so they can use any service they choose over time.
$38.50-55 per hour depending on location and case (during the current time we are experiencing shortage on staff and rates will be quoted per case) Custom Rates apply for Private Educators
$45-65 per hour Night Nanny or NCS
5% processing fee if Crunch Care employee process shopping transaction for client and we bill for items with receipt, no fee if client provides cash payment to shopper for items, hourly billing will be processed by client credit either scenario
$150 Deposit 1+ day of service
$250 Deposit 3+ days of service
$500 Deposit 5+ days of service
Deposit applied to balance if refund required will process at time of billing.

Overtime in CA begins after 8 hours a day and 40 a week. Overtime in FSLA States after 40 hours in a week. See contract for more details.
LONG TERM RATE INFO IF APPLICABLE:
15-18% Rate ranges depending on region and complexity of the search. 20% rate applies for complex searches and for regions such as Los Angeles, New York, San Francisco, Seattle and Portland.
I will need care for:*
If care is not needed put n/a
First Name*
Last Name*
Mobile
Home
Office
Best Number to Contact*
Email*
Current Address*
Street Address Address Line 2 City State ZIP Code
How Did You Hear About Us?
Referred By or Enter Code*
Location of Service (if other than address listed above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Client Name 2
First Last
Mobile
Home 2
Office 2
Best Number to Contact 2
Email 2
Current Address 2
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Any Pets? (Indicate type and number)
Schedule and Assessment
Please be as descriptive as possible when filling out the hours of care you will need. Specify if you will need a.m., p.m., or 24 hour shifts.
Date of Service (if not sure please indicate)
MM slash DD slash YYYY
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Special Requests
Special Needs
The section below applies to all types of care. Please check the boxes that apply to your needs:*
- Live-In
- Live-Out
- Driving
- Driving children to activities
- Misc. errands
- Reading aloud
- Private education support
- Meal planning and preparation
- Grocery shopping
- Changing bed linens
- Sweeping
- Making beds
- Vacuuming
- Dusting
- Laundry
- Household organization
- Dog walking
- Pet feeding
- Plant maintenance
- Mail pickup
- Walks or outdoor activity
- Sleeping in newborns room
- Night feedings or participation in night feedings
- Care of umbilical cord
- Newborn Bathing
- Birth of multiples
- C-Section delivery
- ADLS (Activities of Daily Living)
- Assistance dressing
- Dementia
- Alzheimer's
- Smoking
- Incontinence
- Emptying Colostomy or Catheter Bag
- Bathing Assistance
- Recording (not administering) medication dosing
- Lifting to stand
- Oxygen or Nebulizer use
- Terminally ill
- Transport in or out of bed or wheelchair
- Range of motion activities
- Undergoing Dialysis
- Undergoing Chemo or Radiation treatment
- Feeding tubes
For All Locations: Please print full documents for your records. By entering my initials in the box below, I hereby agree to the terms and conditions stated above in this Client Application and Agreement and to all the terms and conditions in the Crunch Care Agreement.*

Please print and retain all of our agreements as listed at the top of this page.
I am entering my initials to confirm that I have been given the following information: I have been told that TrustLine is California's registry of in-home child care providers, tutors and in-home counselors who have passed a background screening. It was created by the California Legislature in 1987 and is a powerful resource for parents hiring a nanny or baby-sitter. All caregivers listed with TrustLine have been cleared through a fingerprint check of records at the California Department of Justice. This means they have no disqualifying criminal convictions or substantiated child abuse reports in California. TrustLine is administered by the California Department of Social Services and the non-profit Child Care Resource and Referral Network. It is endorsed by the California Academy of Pediatrics. For more information visit www.trustline.org. An employment agency is prohibited by law from placing a child care provider unless the provider is a Trustline applicant or a registered child care provider. Parents can check if a provider is registered on TrustLine by calling 1-800-822-8490. You'll need to provide (1) the person's full name and (2) driver's license number.*
Additionally, by entering my initials in the box below I: (1) agree to provide all of my necessary billing information to Crunch Care; (2) agree to provide Crunch Care with a valid credit card for my billing; (3) understand and agree that Crunch Care shall charge my credit card for all fees, charges and costs pursuant to the Crunch Care, Inc. Family/Client Agreement; and (4) agree to pay all such fees, charges and costs on my credit card to Crunch Care.*

Fees for full employment services will be based on the original booking confirmation. Should the hours be extended they will be audited in our weekly billing based off time card review and will automatically charged to your billing credit card.
By entering my initials below I understand: On all Short-Term Care bookings if case is cancelled after 5pm the day prior to service client will be billed for 4 hours of service fees for the scheduled shift and if cancelled the same day client will be charged the full day of service fees.*
By entering my initials below I understand: I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Crunch Care Inc. has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that Crunch Care Inc. can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Crunch Care Inc. staff, and other Crunch Care Inc. clients and their families. I voluntarily seek services provided by Crunch Care Inc. and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment. I attest that: * I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. * I have not traveled internationally within the last 14 days. * I have not traveled to a highly impacted area within the United States of America in the last 14 days. * I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19. * I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities. * I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19. I hereby release and agree to hold Crunch Care Inc. harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act., or that may otherwise arise in any way in connection with any services received from Crunch Care Inc. I understand that this release discharges Crunch Care Inc. from any liability or claim that I, my heirs, or any personal representatives may have against Crunch Care Inc. with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Crunch Care Inc. This liability waiver and release extends to the with all owners, partners, and employees of Crunch Care Inc.*
**Please print and retain a copy of your completed Client Application for your records.**

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