Oshawa & Whitby Registration Form Oshawa Whitby Ideal Caregivers 4u Registration Form Client's Full Name(Required) First Last Client's Date of Birth(Required) MM slash DD slash YYYY Client's Address(Required) Street Address City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Client's Email(Required) Client's Phone(Required)Services Required(Required) Dementia and Alzheimer's Companionship Care Personal Health Care Services (PSW) Homemaker Companionship Care (MealPrepertion & Light House Cleaning) Hospital Discharge Program Certified Senior Home Safety Specialists (Age Safely At Home) Awake Overnight Care 24-Hour Around-the-Clock End-of-Life Care P.O.A. Name First Last P.O.A. Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands P.O.A. Email P.O.A. PhoneTerms of Service(Required) I agree to the terms of service.Disclosure in connection with electronic communications and e-signatures Please note that by clicking continue and signing this document generated on www.idealcaregivers4u.com you agree that you have reviewed the following disclosure and consent to (i) transact business by electronic means; (ii) receive documents electronically; and (iii) use the Ideal Caregivers 4u Inc. e-signature system. You are not under an obligation to receive documents electronically or use the Ideal Caregivers 4u Inc. e-signature system. You may request to receive hard copy paper documents instead and withdraw your consent at any time by the procedure below. The field is required. Withdrawing consent You may withdraw your consent to receive electronic documents from Ideal Caregivers 4u Inc. at any time. To withdraw consent, you must notify the sending party that you wish to withdraw consent by emailing the sending party directly. Please note that after you withdraw consent, if you choose to proceed after such time and use the Ideal Caregivers 4u Inc. e-signature system, you are consenting to receive and sign documents electronically. You can withdraw consent after the time you consent to use the system by following the procedure outlined above. Scope of consent You agree to receive electronic documents and use the Ideal Caregivers 4u Inc. e-signature system with all related and identified documents provided during your relationship with the sending party. You may withdraw your consent by following the procedures described above. By clicking the Submit button, I agree to the terms of service. * By clicking SUBMIT you consent to receiving SMS messages * Messages and Data rates may apply. Message frequency will vary * Reply Help to get more assistance * Reply Stop to Opt-out of messaging Private Policy - No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.P.O.A Signature(Required)
