Dempsey Center›Registration Forms›Clayton’s House Care Partner Application

Clayton’s House Care Partner Application and Waiver Form

For completion by Care Partner

Submission of this completed Form is a pre-requisite to a Guest’s and Care Partner’s stay at Clayton’s House.

Identification of Care Partner

Care Partner Name:(Required)
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Care Partner Home Address:(Required)
Name of Guest:(Required)
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I agree to submit a valid photo identification upon check-in(Required)

Acknowledgement of the Care Partner Role

I acknowledge that my role as the Care Partner is to assist and support the Guest in all respects, physically and emotionally. I understand that Clayton’s House does not provide aides or other medical or physical supports. I acknowledge that I am required to always remain with the Guest while the Guest is on the site, and to assist with any transportation needs of the Guest. By serving the Care Partner role and signing below, I am representing and assuring that I am: 
  • Knowledgeable of the Guest’s cancer diagnosis and condition and physical limitations and needs to be able to support my stay in Clayton’s House;
  • Able to provide physical support for the Guest, such as daily living, including with respect to ambulating, hygiene, meal preparation, transportation, and housekeeping;
  • Able to assist with administration of any prescribed medications that the Guest may require during the stay;
  • Able to recognize and respond appropriately to an emergency, including being able to contact 911 in the event of an emergency.

Eligibility

A Care Partner is required to meet the following standards. By signing below, I am certifying that I meet these standards and will abide by all Clayton’s House Terms of Stay and requirements.
.(Required)

Accommodations

Are you capable of being assigned to a room on the 2nd or 3rd floor without elevator access?(Required)
Do you and the Guest require a room with two beds?(Required)
Are you aware that there is limited parking on site?(Required)

Waiver and Release

The approval by Clayton’s House to allow me to stay with a Guest as a Care Partner is conditioned upon agreement to abide by all applicable laws and follow Clayton’s House Terms of Stay while on the premises. Failure to comply with the laws and Terms, particularly those that seek to protect the health, safety and wellness of all patrons, may result in refusal of admission or expulsion. Further, I agree to release and waive any and all claims for losses or injury arising from my failure or the failure of the Guest I am accompanying to abide by any laws or Clayton’s House Terms of Stay. In addition, I agree to release and waive any and claims arising out of or related to the transmission or contracting of any communicable disease, including but not limited to COVID-19.

Signature

I agree that my electronic signature is the legal equivalent of a manual signature. I acknowledge that this document contains a WAIVER and RELEASE of claims.(Required)
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