Personal Care Attendant Agreement

Adelphi students who require personal care attendant services are strongly encouraged, where possible, to hire a PCA who is not a family member, friend, or another student.

Student Name*
First Last
Student ID #*
Not sure of your ID? You can look up your Adelphi ID.
Adelphi Email*
Academic Year*
Do you receive services through an agency?*
- Yes
- No
Name of Agency*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Is agency licensed, bonded, and insured?
- Yes
- No
Primary Care Attendant
Please complete the following for the primary care attendant (PCA).
Name*
First Last
Choose ally that apply to the PCA
- Professional Care Provider
- Family Member
- Friend
If family member, what relation?
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Consent
Digital Signature
I agree that I understand that this form must be repeated for each academic year for which I will require PCA services. I further understand it is my responsibility to update the Student Access Office if any of the following information changes during the academic year.

I acknowledge I have received a copy of the Adelphi University Personal Care Attendant Policy and am aware of the steps required to secure PCA services.

Student Access Office

Contact

E-mail

sao@adelphi.edu

Phone Number

516.877.3806

Fax

516.877.3138

Location

Post Hall

Primary Care Attendant