Hotel Adult Care Service Order Form

Please complete with only guests contact phone number and guests email address.

Please do not fill out with the hotel's contact information.

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Please Note: *Return car transportation is to be provided by client.

The Caregiver is PROHIBITED from taking the above adult(s) outside of the Guest’s hotel room and from taking the above Adult/Elder to the hotel pool without prior consent from the Guest. By signing below, Guest indicates that s/he is giving express permission for the Caregiver to take the above to the following locations:

The Guest gives permission to the Caregiver to take photographs and/or videos for the limited purpose(s) communicated between the Guest and Caregiver.

Travel Care Information

Upon completing the request for service form, FCO will confirm the request for service, email the confirmation with profile attached and charge the credit card provided.  Please note: There are no refunds for cancellations received less than 24 hours prior to the start time of the confirmed services.

By completing this order form and signing the credit card form I hereby authorize Family Care Options, Inc. to charge the Credit Card provided for any and all services rendered and/or ordered by Family Care Options staff. The credit card provided will be charged in such a manner as if I were paying in person and signing a transaction slip. I understand there will be a 4% service fee for all telephone and internet credit card orders.

Billing: The rate of service is provided on the company website and furnished upon request. All services are billed in hourly increments, kindly be advised there is a 5-hour minimum charge for all adult care service reservations and a $50.00 return transportation after 9:00 pm. Upon confirming the care scheduled in this said order form, the services will be charged to the credit card provided according to the schedule stated in the email confirmation to follow. In the event the client and/or guest has additional services rendered past the said schedule confirmed, the client and/or guest will be billed a second charge to the original charge.

Rate: Hotel Adult Care: $67.00 per hour minimum 5 hours (up to 1 adult).

Transportation Surcharge: Client will be billed $50.00 for return car transportation after 9:00 pm.

Cancellation Policy: If cancelled less than 48 hours prior to the start date and time confirmed the client will be responsible and billed for the entire schedule of services confirmed. All hourly rates and transportation fees will be charged to the credit card provided. All cancellations received with more than 48 hours notice of the start date and time will receive a refund to the credit card provided.

• Family Care Options holds the right to change the confirmed staff and/ or sitter and/or caregiver without notice in the event Family Care Options receives good information such as but not limited to the current health status of the confirmed staff personnel in which case, Family Care Options will make the necessary change of staff in the best interest of the client according to the original request.

Health Status of Family Member(s) in Need of Care: I understand and agree by signing below that I, the parent and/or primary caregiver has provided any and all information of any pre-existing mental and physical health conditions, health issues, allergies and/or concerns. I furthermore understand I am required to disclose any and all mental and physical medical conditions and/or concerns and/or pre existing mental and physical health concerns, allergies, issues or conditions of the adult(s) and/or regarding the adult(s) that care was requested for in order for Family Care Options to provide appropriate care. I further understand, in the event I do not provide health information for the adult(s) needing care, I, the primary caregiver, take full responsibility and will be held solely liable for any and/ all causes of injury, damages loss, claims, suits or liability to the caregiver referred by Family Care Options in this Service Order Form. I further understand that not disclosing this information may have compromised the care of the adult requesting care and may have therefore compromised the ability of Family Care Options to provide an appropriate caregiver and care for the adult(s). 

TOYS and FOOD: Our sitters are not authorized to bring toys or food to a job. 

Please Note: Upon submitting this service order form Family Care Options will confirm the request and email you a confirmation and charge the credit card provided. Submitting this request for service form it’s considered an order form. For additional information about our rates and policies, please contact our office before submitting this request.

Method of Payment: All major credit cards accepted and billed upon confirming the schedule of this said order form.

By filling out and signing this credit card authorization form:

I hereby authorize Family Care Options, Inc. to charge the Credit Card provided for any and all services rendered and/or ordered by Family Care Options staff. The credit card provided will be charged in such a manner as if I were paying in person and signing a transaction slip. I understand there will be a 4% service fee for all telephone and internet credit card orders.