MEMBERSHIP APPLICATION

Assistance Needed

1YOUR INFORMATION DATE

FIRST NAME/MIDDLE NAME LAST NAME

DATE OF BIRTH/AGE SIGNATURE

Email Address

City/State/Zip PHONE CELL

Date Service to Begin Service Needed

What is your current mode of transportation?

Do you currently drive? Yes_____No______ Driver’s License#/State

Household Income: ______________Annual/Monthly Status _________Single_______Married
Additional Assistance for this service: yes/no Number in Household ____________
If yes, how much:____________________________ Race: (optional) A/A_______Hispanic_______Asian______
Total Expenses: __________________Annual/Monthly Caucasian__________American Indian______Other_____

Services you want to receive: Check all Special Needs: Walker ____Wheelchair_____Oxygen___
that apply. Cane_____ Hearing Impaired_____Visually Impaired____
Transportation Light Housekeeping Dog Walking
Local Errands Daily Call Check Occasion Planning
Yard Work Handyman service
Small Repairs Respite Care
Doctor Accompaniment Paperwork Assistance
Home Visits Daily________ (weekly)__________ Computer Assistance
Light cooking/warm-up Companionship
Any other services needed:

Mailing Address: P. O. Box 4419; Capitol Heights, MD 20791

301-909-5600 (phone) 301-200-5600 (fax)
www.pathsofpgc.com
 MEMBERSHIP APPLICATION
Assistance Needed

START DATE END DATE

Number of Hours Needed

Emergency Contact Information PHONE EMAIL

Name relationship Alt phone:

Address City/State/Zip

Social Worker (If applicable)

NAME Phone EMAIL

A home visit is required prior to scheduling. Please let us know the best day and time to visit. ___________________

Most of PATHS, LLC services are offered at a flat rate of $18 per hour for a minimum of 3-hour assignment.
Transportation only is offered at a flat rate of $35 with a minimum of 2-hours. Ask about our senior’s 10% discount.
In some cases, scholarships may apply.

We make life a little easier for you or someone you love by providing services in the home

INDEMNIFICATION CLAUSE: I agrees to indemnify and hold Peers Available To Help Seniors (PATHS, LLC) and its officers,
directors, volunteers, associates, staff and other members blameless from any and all actions, claims, damages, or
liabilities arising from any services provided to or receiving of the Senior, or arising out of, or in connection with any
breach of this agreement by PATHS< LLC.

Signature Print Name Date

Mailing Address: P. O. Box 4419; Capitol Heights, MD 20791

301-909-5600 (phone) 301-200-5600 (fax)
www.pathsofpgc.com