COVID-19 Vaccine Policy

COVID-19 Vaccine Policy

Acknlowledgements & Election
This form is to be used as an electronic acknowledgement for the Home Instead COVID-19 Vaccine Policy. The full policy can be reviewed and downloaded here: http://ricaregiver.com/covid-policy
ACKNOWLEDGMENTS*

I have received, read, and understand the attached COVID-19 Vaccine Policy.I agree to promptly provide the requested documentation of my COVID-19 vaccinationI have been advised that I have a right to receive a copy of this document.
ELECTION
I hereby elect to (choose one):

Opt-In to receive COVID-19 vaccination in accordance with this policy
and:

Home Instead MAY share information about my vaccination status with clients I serve or to the facilities in which clients I serve may be located, upon request.Home Instead MAY NOT share information about my vaccination status, except as required by law. (*)
Opt-Out and Home Instead may not share vaccination status, except as required by law. (*)
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Every Home Instead franchise is independently owned and operated.

100 Jefferson Blvd. Suite 310 Warwick, RI 02888 | T: 401.214.2456 | F: 401.264.8019

7291 Post Rd. North Kingstown, RI 02852 | T: 401.667.2923 | F: 401.667.2928
Should be Empty: