Do you want to find out more about Club 24 home care services and how these services might benefit you or a loved one? Please take a moment to complete this form. Club 24 staff will contact you. You may also call us at 206-547-2424 to speak directly with a staff member.

Personal information

Please Check One: Mr. Mrs. Miss Ms. Your Name (first and last): Phone: Address: Date of Birth: Will there be a 2nd Member in your household: Yes No     2nd Member's Name: Mr. Mrs. Miss Ms.

What services do you need at this time? (Please check all that apply)

Personal Care Services: Yes Hot, home-delivered meals Yes Light housekeeping, errands Yes Companionship Yes Other:

How did you hear about Club 24?

Club 24 member (name) Yes Family Member / Relative Yes Friend Yes Club 24 Website Yes Newspaper Ad (which one) Yes Brochure (where) Yes Agency / Senior Center (specify) Yes Other:

Thank you for completing this Home Care Request form with Club 24 Senior Living at Home®. When you click on the button below, your form will be forwarded to our office. A Club 24 staff member will be in touch with you. You may call us directly at 206-547-2424 (Monday through Friday 8:00 am – 5:00 pm PST) to inquire further about Club 24 services. Thank you. We look forward to serving you.