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Consumer: Contract for Services
Contract for Services
Name
and
Name 2
agree on the Medical Waiver Services of:
Personal Support
Respite
Life Skills 1
Days per week, hours and times required
Sunday Hours
Sunday Times
Monday Hours
Monday Times
Tuesday Hours
Tuesday Times
Wednesday Hours
Wednesday Times
Thursday Hours
Thursday Times
Friday Hours
Friday Times
Saturday Hours
Saturday Times
I agree to the truth and honesty of this said agreement:
Consumer's Name:
❌
Date
Legal Guardian
❌
Date
Director's Signature
Date:
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