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):
Email Address:
Phone:
Address:
Date of Birth:
Will there be a 2nd person in your household:
Yes
No
2nd Person's Name:
Mr.
Mrs.
Miss
Ms.
What services do you need at this time? (Please check all that apply)
Personal Care Services:
Yes
Care Calls
Yes
Light housekeeping, errands
Yes
Companionship
Yes
Other:
How did you hear about Club 24?
Club 24 Client (name)
Yes
Family Member / Relative
Yes
Friend
Yes
Club 24 Website
Yes
Other Website (which one)
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 HomeŽ.
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.
