Name *

First Name

Last Name

Phone *

(###)

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Which duties will your companion perform?

Check all that apply

companionship/conversation

activities of daily living (help grooming, bathing, dressing, etc.)

housekeeping

cooking

laundry

shopping & errands

escort on outside activities

operate mechanical lifts (to change body position)

care for house pets

medication reminders

other (please describe below)