RESPITE CARE WORKER
LIABILITY WAIVER
I, _______________________________
am not a licensed respite worker or care provider. I am a volunteer with a
heart for service and am working to give a Family Caregiver some relief. While
I will do everything in my power to provide the best of care in the absence of
this Loved One’s usual caregiver, I am in no way infallible. I will follow the
directions of the usual caregiver to the best of my ability and will carry out
my duties with tenderness and compassion.
I am, am not (circle one) certified in CPR. I will call the necessary emergency
personnel if there is a problem beyond my control. I will not be held
responsible for any situation that might arise to cause harm or injury to this
Loved One, barring negligence or abuse on my part.
The Family Caregiver relieves me of
all liability in the event of injury, harm, or death, to this Loved One in my
charge for the date or dates listed below.
Date(s): _________________________________________
____________________________________ ____________________
Respite Worker Volunteer Date
____________________________________ ____________________
Family Care Provider Date
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