REQUEST FOR ASSISTANCE FORM:

Client contact information

Referral information (if applicable)

Business phone:

Personal information:

Have you looked for a commercial solution?*

YES   NO

If yes, please explain:

Financial support

What agency – if any – provides you with financial support in acquiring assistive devices (ie: auto insurance, WCB, social services, CPP/Social Security, health insurance, etc)?:

Publicity

We reserve the right to use your device, and any photographs of your device to promote or fund raise for Tetra.

Can we use photographs of you for these purposes?   YES   NO

How did you find out about our program?*

(ie: TV, radio, magazine, newspaper, we4bsite, health professional, family/friend, disability organization, prior Tetra client, or other source)

Further information and disclaimers

Tetra is a volunteer driven, not-for-profit society.  The cost of materials and volunteer's travel expenses are to be reimbursed by the client.  All money transactions are to be handled through the local Tetra Chapter Coordinator. 

The client understands that he/she is in control of the services and Tetra simply provides volunteer help to assist.  Tetra recommends that the client and volunteer be accompanied at all meetings by a third person of the client's choosing.  After your project is complete we ask that you write a thank-you letter to the volunteer.

Please read and sign the following Exclusion of Liability, No Action and Indemnity clauses.  By signing below, you will waive certain legal rights including the right to sue.  Please read carefully.

In consideration of the services to be provided to me by Tetra Society of North America and/or its member, directors, volunteers, officers, agents, representatives, employees and assigns (collectively, the "Releasees"), I hereby agree as follows:

1. EXCLUSION OF LIABILITY - not to hold the Releasees, or any of them, liable for any losses, damages or injuries that I may suffer, whether to person or property, howsoever caused, including negligence, breach of contract and breach of any statutory duty or other duty of care, on the part of the Releasees, or any of them;

2. NO ACTION - not to bring any action, proceeding, or claims against the Releasees, or any of them, for any losses, damages or injuries that I may suffer, whether to person or property;

3. INDEMNITY - to indemnify and hold harmless the Releasees and each of them, from and against all claims, actions, costs, expenses and demands brought by any person in respect of death, injury, loss or damage, whether to person or property, resulting directly or indirectly from my participation with the Releasees and their projects and services.

I have read and understood this agreement and am aware that by signing this agreement I am waiving certain legal rights which I or my heirs, next of kin, executors, administrators and assigns may have against the Releasees.

NOTE: a parent or guardian and /or a trustee committee, or other legal representative must also read this form and sign below if the client is under the age of 19 years and/or has a legal representative (i.e. trustee, committee) appointed on his or her behalf.