Family App for ConnectCareHero ConnectCareHero Family App™ Request Access Fill out the form below to request access to ConnectCareHero’s Family App™ Please enable JavaScript in your browser to complete this form.Your Name *FirstLastYour Email Address *Resident's Name *FirstLastCommunity or Organization *The community, company, or organization associated with your family member.Your Relationship to the Resident *Please Enter This Person's Relationship to The ResidentDaughterSonGranddaughterGrandsonSpouseOther Family MemberFriend / OtherRequest Family App Access for Yourself? *YesWould you like to request access to the ConnectCareHero Family App uing your contact informaiton above? Request Family App Access for Others? *YesNo, I am only requesting access for myself. Would you like to request access to the ConnectCareHero Family App for other people? If so, click "Yes' and enter their contact information in the fields that populate below. Add Other People to Access the Family AppPlease list the name, relationship to resident(s), and contact information for family members and other key members of your resident’s circle of care whom you authorize to receive updates via the ConnectCareHero family app. Answer "Yes" after each entry to add additional people.Full Name (Entry #1) *FirstLastRelationship (Entry #1)Please Enter This Person's Relationship to The ResidentDaughterSonGranddaughterGrandsonSpouseOther Family MemberFriend / OtherEmail (Entry #1)Would You Like to Add Another Person to Receive Access to Family App??YesFull Name (Entry #2) *FirstLastRelationship (Entry #2)Please Enter This Person's Relationship to The ResidentDaughterSonGranddaughterGrandsonSpouseOther Family MemberFriend / OtherEmail (Entry #2)Would You Like to Add Another Person to Receive Access to Family App???YesFull Name (Entry #3) *FirstLastRelationship (Entry #3)Please Enter This Person's Relationship to The ResidentDaughterSonGranddaughterGrandsonSpouseOther Family MemberFriend / OtherEmail (Entry #3)Would You Like to Add Another Person to Receive Access to Family App????YesFull Name (Entry #4) *FirstLastRelationship (Entry #4)Please Enter This Person's Relationship to The ResidentDaughterSonGranddaughterGrandsonSpouseOther Family MemberFriend / OtherEmail (Entry #4)Continue to Sign and SubmitCheck only one of the following: *I authorize the Community Organization listed above to share resident’s activities, events and photos / videos to thelisted family members via the secure, HIPAA-compliant ConnectCareHero family app.Healthcare POA Signature Clear SignatureDatePreviousSubmit