Care Network - Help Request Form

Personal Information

First Name

Middle Name

Last Name

Preferred Name (If Applicable)

Phone Number

Date of Birth

Marital Status

Married

Single

Widow

Home Address

Address 1

Address 2

City

State

Zip

Emergency Contact Information

Emergency Contact name

Emergency Contact Relationship

Emergency Contact Phone

Emergency Contact Email

Questionaire

Are There Any Health Issues We Should Be Aware Of?

Name / Age / Relationship of Others Living in Your Home

Help Requested

How Did You Hear About Catalyst Care Network?

RELEASE OF LIABILITY WAIVER - I understand and acknowledge that my involvement in this endeavor with Catalyst, its agents and contractors, and any partnering organizations, is voluntary. I understand and acknowledge my willingness to allow myself and my property to be associated with this Catalyst activity in the manner described on the Catalyst Care Network webpage. I understand and acknowledge that this Activity may pose the potential risk of injury, illness, or damage to my person and/or property. I also realize that Catalyst and its personnel, agents, or volunteers, or any other person or entity associated with this Activity, may not be professionally trained for this Activity, and are not legally or financially responsible or liable for any claim arising from any injury, illness, or damage done to my person and/or property during this Activity.

Agreed

Decline

The information I have provided is true and accurate

Signature Date