Acknowledgement - Please read and provide your signature below
In completing this application, I confirm that all information is correct to the best of my knowledge. I also acknowledge that services will be provided by volunteers in response to each individual service I request. I give my permission for a member of Interlakes CommunityCaregivers, Inc. to confirm my appointment with a service provider, if necessary. My signature will be kept on record by ICCI and will apply to all services provided. I understand that ICCI will keep all information I provide confidential.