Caregiver Participation Agreement & Signature Form

PLEASE READ THIS CAREFULLY AS IT IS AN AGREEMENT BETWEEN YOU AND STEVE’S WAY WHICH MAY HAVE AN IMPACT ON ANY FINANCIAL SUPPORT YOU MAY RECEIVE FROM STEVE’S WAY.

I HEREBY CERTIFY that the information provided to Steve’s Way by the Caregiver (“Caregiver”) regarding the Care Recipient (the “Care Recipient”) is true and correct to the best of my knowledge. Failure to provide accurate or truthful information will result in immediate termination of any assistance provided by Steve’s Way and will create a responsibility of repayment of the original account balance provided by Steve’s Way.

I understand that no one living in the household of the Care Recipient may be paid to provide services through Steve’s Way. Should this rule be broken, I understand services will immediately be terminated.

I will notify Steve’s Way immediately if the Care Receiver begins receiving services through the Community Long Term Care Program, VA Aid or Medicaid.

Consent to Release Information

The information on this form is required by Steve’s Way and will be kept confidential and guarded against unofficial use. Some of the information gathered may be used to refer or provide appropriate services on behalf of the Care Recipient. The Care Recipient has the right to refuse to provide the information. However, by refusing to answer particular questions, the Care Recipient may be waiving his/her right to receive assistance from Steve’s Way. Steve’s Way reserves the right to reject or deny assistance to applicants of Steve’s Way for any reason. The undersigned understands and agrees that the completion of any forms for Steve’s Way does not create a contract in any form with Steve’s Way or a promise of further financial assistance from Steve’s Way.