Independent Contractor/Non-Employee Agreement (SAMPLE)
This agreement is made between:
(Family of) _______________________________ and (Caregiver) _____________________________ , and is intended to reflect the
following terms.
Work Schedule:
The work schedule will be as follows:
Day of the Week Hours Scheduled Total Hours
Total Weekly Hours ______
Compensation:
All wages shall be paid and duly reported according to the terms defined by the Internal Revenue Service as 1099 Non-Employee
Independent Contractor earnings.
The Family agrees to compensate the Caregiver at the rate of $______ per Hour (w/15-Minute incremental).
Hours in excess of 40 hours in a 7-Day period shall be compensated at the rate of $______/Hour.
24-Hour Respite and/or Live-In compensation is agreed to as follows:
____________________________________________________________________________________________________
Wages will be paid __ Daily __Weekly __Semi-monthly __Monthly.
Specific Duties/Responsibilities/Schedule:
1. _____________________________________________________________
2. _____________________________________________________________
3. _____________________________________________________________
4. _____________________________________________________________
5. _____________________________________________________________
6. _____________________________________________________________
Caregiver Responsibilities: (Please initial)
I ____ agree to carry out the assigned duties and responsibilities, according to the procedure(s) explained.
I ____ agree to a two weeks advance notice when time off is needed.
I ____ agree to call the Family with as much advance notice as possible if unable to report to work as scheduled, due to unforeseen
emergencies (illness, transportation, weather, family emergency, etc.)
I ____ agree to give two (2) weeks notice, if I intend to terminate my services.
I ____ agree to respect the Family’s confidentiality.
I ____ agree to respect and not misuse or damage any of my client’s personal belongings or real property.
I ____ agree to hold Family harmless for any personal injuries arising/resulting from any duties or responsibilities.
I ____ have read and understand the Duties and Responsibilities expected of me.
I ____ understand and agree that nothing contained in this agreement, or conveyed during any interview, is intended to imply or create
an Employer/Employee relationship or obligation.
I ____ further understand and agree that my services will be “at will” and without fixed term, and may be suspended or terminated at
any time, with or without cause, at the option of either myself or the Family.
X __________________________ _____________ X _____________________________ _____________
Signature of Caregiver Date Signature of Family Representative Date
______________________
Witness
Monday
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Tuesday
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AM PM
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Wednesday
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AM PM
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Thursday
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AM PM
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Friday
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AM PM
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Saturday
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AM PM
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