Request for Assistance

Form updated: 9-Dec-2007

Tetra's services are offered at no charge. Clients pay only for materials and the volunteer's expenses. The Tetra Society operates on a charitable, non-profit basis with no core fundraising, relying instead on charitable contributions from a variety of sources.

		Demande d'Assistance (version française).
		Click here to print form (fax to 604-688-6463).

CLIENT INFORMATION:	* Fields are mandatory.

Client name: *
Email: *
Address: *
City: *
Province/State: *
Postal/Zip Code: *
Residence Phone (area code): *
Business Phone (area code):
Fax (area code):

REFERRAL INFORMATION (If applicable)

Is this a referral?:	Yes No
Name of OT/PT making referral:
Business Phone (area code):
Cellular (area code):
Fax (area code):
Email:

AGE

0 - 12 (actual age is: )	13 - 18 (actual age is: )	19 - 25
26 - 35	36 - 55	56 - 65
65+

NATURE OF DISABILITY

ALS	Arthritis	Cerebral Palsy
Multiple Sclerosis	Muscular Dystrophy	Paraplegia
Quadriplegia	Spina Bifida
Other:

Describe the problem that needs a solution:

Have you looked for a commercial solution? Yes No

Please explain:

Do you have any suggestions on how this problem could be solved? Yes No
(If a volunteer is assigned, you will work together to solve the problem.)

What agency provides you with financial support in acquiring assistive devices?

Auto Insurance	CPP/Social Security	Health Insurance
Social Services	WCB	None
Other:

How did you find out about our program?
(Please check one and specify in space provided):

Disability Organization	Magazine	Radio
Family/Friend	Newspaper	TV
Health Professional	Prior Tetra Client
Specify:

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

TETRA POLICY

Tetra is a volunteer driven, not for profit society. Clients pay only for materials and the volunteer's expenses. 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.

By clicking the submit button below, I certify that 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 (ie. trustee, committee) appointed on his or her behalf.


Date *	Applicant's Signature *

Date *	Witness Signature *

Date	Parent/Guardian/Trustee Committee Signature

Date	Other Legal Representative

You must check the 'I Agree' checkbox to validate this form:

I AGREE: