Client Security Release

Full Name:

Phone:

I authorize an employee of Home Instead Senior Care to assist me with these activities; I release SSMW, LLC dba Home Instead Senior Care from any liability due to misuse of these items:

Assist in balancing my checkbook

Assist in my online banking

Assist in making bank deposits/withdrawals including ATM

Paying bills: with checks or online

Cash checks

Authorized to use my credit card for purchases that I designate

I authorize an employee of Home Instead Senior Care to have the following items, and I release SSMW, LLC dba Home Instead Senior Care from any liability or claims regarding these items:

I am providing a Home Instead employee access to my home with a lockbox key code or similar

I am providing a Home Instead employee the following gift:

Gift Description

Contact

561-409-5980

Boca.Office@HomeInstead.com

HHA License #: 299995091