Guardian Angels Sitting Service
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Wathing Over All That Matters and Trusted by Families Since 2009
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Book An Elderly Companion

This form is for if you are requesting an elderly companion in your home or hotel.

*How did you hear about Guardian Angels Sitting Service LLC?
*Location Services Needed for:
New Jersey
Florida
Delaware
Ocean City, MD
*Person Requesting Services Name: ( First and Last)
*Relation to Member:
*Do you have permission to request these services for the member ?
Yes
No
*Elderly Adult First Name:
*Elderly Adult Last Name:
*Home Address:
*City:
*State:
*Zip Code:
*Cell Phone Number:
*Alternative Phone Number:
*Email:
Hotel/Resort Name: ( If applicable)
Room Number:
Sitting Location Street Address: (if different then above)
City:
State:
Zip Code:
Dates being Requested

3 hour minimum is required

*Day:
*Date: (MM/DD/YY)
*Start Time: ( include AM or PM)
*End Time: ( include AM or PM)
Day:
Date: (MM/DD/YY)
Start Time: ( include AM or PM)
End Time: ( include AM or PM)
Day:
Date: (MM/DD/YY)
Start Time: ( include AM or PM)
End Time: ( include AM or PM)
Day:
Date: (MM/DD/YY)
Start Time: ( include AM or PM)
End Time: ( include AM or PM)
*Companion Preferences:
Male
Female
No Preference
Preferred Age Range of Companion: (16+)
Preferred Qualities/Skills/Abilities:
*Elderly Adult Gender: ( Male or Female)
*Elderly Adult Age:
*Elderly Adult Martial Status:
*How can a Guardian Angel companion best help this elderly adult?
Companionship/Conversation
Local Outings/Walks Outside
Games/Puzzles
Light Meals (sandwichs/snacks)
Errands ( prescriptions, dry cleaning, movie rentals, post-office)
Grocery Shopping
Doctors Visit
Ambulatory Status: Does this member use an assistive device of any kind to walk? If yes please list type:
Does this member use a wheelchair at any time? If yes when?
Is this member able to transfer in and out of the wheelchair and in and out of a car independently?
Is this member able to fix meals for themselves?
Is this member able to use the restroom independently?
Please list all medical conditions, if any, and any medication taken for that specific condition:
Does this member have any health condition that could be contagious to another person in any way?
Please list any previous surgeries and/or hospitalizations and the date that each took place:
Please list any special needs or diet restrictions:
Please list any hobbies, special interests, including any games or activities that they enjoy playing/doing:
Job directions or Special Instructions:
*Emergency Contact First Name:
*Last Name:
*Relation:
*Cell Phone Number:
Terms and Conditions:

Please note: We are NOT a homecare or nursing agency. Our sitters are NOT responsible for personal hygiene, bathing or assisting the member in the bathroom. All elderly members MUST be independent in the bathroom and be able to ambulate independently with or without an assistive device. If the member is in a wheelchair, they must be able to transfer in and out of the wheelchair, if need be, independently. Anyone taken out to a Doctors visit or outing MUST be independent in transfers in and out of the car as well as independent in ambulation with or without an assistive device. Our sitters are not trained in transfers or ambulation and they are not nurses. Our sitters are professionally screened, have a clear background check and have multiple references that are checked. They have experience and enjoy spending time with the elderly. It is our primary concern that both our sitters and your loved ones remain safe at all times. It is our goal to provide you with a responsible, compassionate, personable, fun-loving sitter who will help enhance and improve the life of your loved one!

Terms and Conditions
Applicant (Cardholder if different) acknowledges and accepts full responsibility and guarantees payment for all services requested by me or on my behalf, either verbally or in writing, whether or not such services are authorized by Applicant, (or Cardholder if different). Applicant (or Cardholder if different) agrees that Guardian Angels Sitting Service of Broward and Miami- Dade County LLC (“Agency”) may pursue all avenues of collection, including use of collection agencies, and authorizes Agency to prepare and submit credit card charges using any of the charge cards listed above to recover all charges and all other unpaid amounts due including those for failure to pay on time for services rendered through membership, damages for returned check charges in the amount of $30.00 per check, and cancellation fees.


I, Applicant, give my permission for this information about my family and my children to be shared with babysitters that may be caring for my children. I, Applicant understand that the Agency is not responsible for any damage, theft, or negligence that may occur as a result of having a sitter care for my children. I understand that the Agency performs background checks based on the information that the sitter provides to Agency. The Agency is not responsible if the sitter does not provide accurate and true information and is not responsible for any history that may not come up when the background check is completed.


I have read and understand that there is a 24-hour cancellation notice required or a cancellation fee in the amount of the 4-hour minimum for both the Agency and the sitter will apply. The undersigned represents that he or she has read and fully understands that this document is a release of liability.


RELEASE OF LIABILITY AND INDEMNIFICATION 
Applicant releases and forever discharges Guardian Angels Sitting Service of Broward and Miami- Dade County LLC ("Agency") and their officers, directors, agents, (collectively, the “Released Parties”) from any and all actions, costs, suits, demands, claims, damages, losses and liabilities (including reasonable attorney fees) of any type or kind whatsoever occurring from or connected with the issuance, receipt, or use of such Information by Agency and agrees to indemnify, defend, and hold harmless the Released Parties from and against any and all demands, claims, damages to persons, losses and liabilities (including reasonable attorney fees), arising out of, caused by, resulting from, or in any way related to the issuance, receipt, or use of such information.

ADDITIONAL TERMS AND CONDITIONS

  1. Agency Referral Services. Applicant and Cardholder, if different, (collectively "Applicant") agree to pay Guardian Angels Sitting Service of Broward and Miami- Dade County LLC ("Agency") for referring an independent contractor to Applicant or referring an Applicant to an independent contractor. Agency agrees to make its best effort to provide independent contractor referral services ("Services") to Applicant under and pursuant to this agreement on a day-to-day, as needed, basis and that Applicant in his/her sole discretion shall determine his/her need, if any, for Services or the continuation of Services as may be provided by Agency pursuant to this agreement. Agency is a professional referral agency specializing in referring babysitters, pet sitters, and elderly companions in Broward and Miami- Dade County, Florida.
  2. Independent Contractor. The status of each individual ("Independent Contractor") providing temporary services to Applicant is that of an "independent contractor" and not of an agent or employee of Agency and, as such, Independent Contractor shall not have the right or power to enter into any contracts, agreements, or any other commitments on behalf of Agency. Childcare, Pet care or Elderly companion worker referred to Applicant by the agency in temporary assignments are employees or agents of Applicant and not employees or agents of Agent. Applicant and Agency agree that should an Independent Contractor be found liable for any loss or damages resulting from a failure to perform any of their obligations including, but not limited to negligence, breach of contract or otherwise, then liability lies with the Independent Contractor and not Agency.
  3. Compensation. The amount owing to Agency under this agreement reflects the amount of compensation owing Agency pursuant to Applicant's promise in the matter of Agency's Services. Credit card information is provided above as payment security. Applicant authorizes the use of credit card information pursuant to this Agreement. In the event of non-payment of any fees or charges incurred hereunder, Applicant authorizes Agency to automatically charge to the provided credit card the full amount incurred.
  4. Minimum Compensation to Agency. Applicant and Agency agree that provision of Services shall be conditioned upon a minimum compensation for four (4) consecutive hours of sitting. Regardless of the number of Independent Contractor hours Applicant actually utilizes, Applicant agrees to tender payment for at least four (4) hours of sitting services. In the event that Applicant cancels scheduled sitting services without giving 24-hour advance notice of such cancellation to Agency (not Independent Contractor), Applicant agrees to pay the agreed minimum four (4) hour referral charge directly to Agency.
  5. Commencement, Renewal and Cancellation Provision. This agreement shall take effect upon receipt of a completed request for Services and payment of the nonrefundable membership dues for annual members and booking fees for daily, weekly, and monthly members. All membership dues are payable in advance and considered incurred in full upon commencement of Services. Daily memberships shall expire after one (1) day. Annual memberships shall expire one (1) year from the first date of Service. Unless notified in writing 30 days prior to ending of annual membership, members on file card will be automatically charged.
  6. Confidentiality Provision. Applicant and Agency agree that the names of independent contractors are and shall remain the exclusive property of Guardian Angels Sitting Service of Broward and Miami-Dade County LLC, are confidential, are of great value to the Agency, and constitute trade secrets. Applicant and Agency further agree that all information used by the Applicant in obtaining the services of the Agency’s independent contractors including, but not limited to; (1) time sheets; (2) service invoices; and (3) any documents containing the names or identifying information of independent contractors are trade secrets, are confidential, and are the valuable property of the Agency. Any such information obtained by the Applicant during the course of this agreement is and shall remain the property of the Agency. Applicant and Agency further agree that during this agreement and the period of three (3) years immediately after the termination of this agreement, Applicant will not, either directly or indirectly make known or divulge the names, phone numbers, addresses, or identifying information of any of the Agency’s independent contractors, nor shall Applicant divulge any confidential information received from the Agency to any person, firm, or corporation. Applicant and Agency agree that Applicant's unauthorized disclosure or use of Agency's confidential information or trade secrets would irreparably damage the Agency. Applicant agrees that upon Applicant’s violation of this Confidentiality Provision, Agency shall be entitled to $3,000 per incident as liquidated damages. Any violation of this provision shall further entitle Agency to immediate injunctive relief.
  7. Non-Solicitation Provision. Applicant also agrees that during this agreement and the period of three (2) years immediately after the termination of this agreement, the Applicant will not, either directly or indirectly call upon, solicit, divert, or take away any of the Agency’s independent contractors, with whom the Applicant became acquainted due to any dealings, communications, agreements, or other relations with the Agency. Applicant and Agency agree that Applicant's unauthorized solicitation of Agency’s Independent Contractors would irreparably damage the Agency. Applicant agrees that upon Applicant’s violation of this Non-Solicitation Provision, Agency shall be entitled to $3,000 per incident as liquidated damages. Any violation of this provision shall further entitle Agency to immediate injunctive relief.
  8. Indemnity Provision. Although Agency makes every effort to refer Independent Contractors who it believes possesses the highest quality and abilities for each specific assignment, the Agency cannot represent or warrant the actual abilities of each Independent Contractor. Applicant agrees to hold Agency, its officers, agents, and employees harmless for all claims, including, but not limited to claims for damage, destruction, theft, or accidents which may arise out of, touch upon, or be in any way related to this agreement or any services provided by Independent Contractor to Applicant. The agency does not carry insurance to cover driving risk, nor does it make any representation as to the Independent Contractor’s driving ability. All responsibility in allowing the applicants child(Ren) to ride with the Independent Contractor is and shall be borne by the Applicant. The Applicant understands the agency is not liable for any damage or harm done in connection with the child(ren) being in a car/driven with/by the Independent Contractor. For a fee of $15, the Applicant can request that the Agency provide the driving record of the Independent Contractor with a 48-hours advance notice.
  9. Applicant's Remedies. Applicant and Agency agree that should Agency, and/or its officers, employees and agents, be found liable for any loss or damages resulting from a failure to perform any of its obligations including, but not limited to negligence, breach of agreement or otherwise, then Applicant and Agency agree that Agency, and/or its officers, employees and agents', liability shall be limited to a sum equal to a four (4) hour referral service charge for Applicant.
  10. Agency's Remedies. In the event of Applicant's breach of the above Non-Solicitation or Confidentiality provisions, Applicant and Agency agree that it would be impossible to ascertain the exact damages of Agency and that Agency shall be entitled to receive from Applicant as liquidated damages a sum equal to $3,000.00 per incident. This is not meant to be a penalty nor a windfall to the Agency, but a method to compensate Agency for Agency’s reasonably expected lost profits, loss of goodwill, and other associated damages. This provision is not intended to limit other damages recoverable by the Agency, or the Agency's right to injunctive relief to enforce this agreement.
  11. Legal Fees and Court Costs. Should the Agency resort to the use of an attorney regarding any matter arising out of touching upon this agreement, the Agency shall be entitled to recover from the Applicant its reasonable attorney's fees, court costs and related expenses.
  12. Binding Arbitration - In the event of any dispute between the parties which arises under this Agreement, such dispute shall be settled by arbitration in accordance with the rules for commercial arbitration of the American Arbitration Association (or a similar organization) in effect at the time such arbitration is initiated, and subject further to the provisions of the Florida Uniform Arbitration Act, incorporated by reference. A list of arbitrators shall be presented to the Claimant and Respondent from which one will be chosen using the applicable rules. The hearing shall be conducted in the City of Fort Lauderdale Florida, unless both parties consent to a different location. The decision of the arbitrator shall be final and binding upon all Parties. The prevailing party shall be awarded all of the filing fees and related administrative costs. Administrative and other costs of enforcing an arbitration award, including the costs of subpoenas, depositions, transcripts and the like, witness fees, payment of reasonable attorney's fees, and similar costs related to collecting an arbitrator's award, will be added to, and become a part of, the amount due pursuant to this Agreement. Any questions involving contract interpretation shall use the laws of Florida. An arbitrator's decision may be entered in any jurisdiction in which the party has assets in order to collect any amounts due hereunder. Nothing herein shall be construed as to limit Agency’s right to pursue injunctive relief for perceived violation(s) of the Non-Solicitation or Confidentiality Provisions contained herein in a court of competent jurisdiction.
  13. Governing Law and Venue. The parties agree that this agreement shall be governed by, construed and enforced in accordance with the laws of the State of Florida. The venue for any legal action or proceeding shall be in Fort Lauderdale, Florida.
  14. Severability Provision. The provisions in this agreement shall be severable which is to say that should a portion of this agreement be declared invalid or unenforceable, that same would not alter the remaining provisions.
  15. Transferability. The rights and obligations under this agreement are personal to Applicant and Agency and may not be assigned or transferred to any other person, firm, corporation or other entity without the prior written consent of the parties.

No Waiver of Breach and Entire Agreement. TIME IS OF THE ESSENCE IN THIS AGREEMENT. The failure of either party to this agreement to insist upon the performance of any of the terms and conditions of this agreement, or the waiver of any breach of any of the term and conditions of this agreement, shall not be construed as thereafter waiving any such terms and conditions, but the same shall continue and remain in full force and effect as if no such forbearance or waiver had occurred. This agreement constitutes the entire agreement between the parties and any prior understanding or representation of any kind preceding the date of this agreement shall not be binding upon either party except to the extent incorporated in this agreement. Modifications of this agreement shall be binding only if evidenced in writing signed by Applicant and Agency.

By submitting this application, we the guardians/parents request the Agency refer a childcare worker (Independent Contractor) for our employment of same.

 

Payment Terms:

Applicant (Cardholder if different) acknowledges and accepts full responsibility and guarantees payment for all service requested, either verbally or in writing, whether or not such services are authorized by applicant, (or cardholder if different). Applicant (or cardholder if different) agrees that Guardian Angels Sitting Service LLC. May pursue all avenues of collection, including use of collection agencies, and authorizes GASS to prepare and submit credit card charges using any of the charge cards listed above to recover all charges and all other unpaid amounts due including failure to pay on time for services rendered through membership, damages for returned check charges in the amount of $30.00 per check and cancellation fees.

*I the applicant, have read, understand and agree to rates, procedures, credit card authorization and all terms and conditions listed above. ( Full Name)
CREDIT CARD INFORMATION - SECURE SITE
*Credit Card Type:
Visa      Mastercard      Discover      American Express
*Name on the Card:  *Credit Card Number:   
     
*Expiration Date:   *Security Code:    
     
*Billing Street Address:        
   
*Billing City:   *State:   *Zip:
   
 
 
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