PLEASE NOTE: This application must be filled out by a health care professional. Any information provided in this survey will NOT be submitted to a third party (i.e., insurance company) or be entered into a medical record. Health care providers, please answer questions to the best of your ability. We greatly appreciate your time and effort.

Release of Information and Assumption of Risk, Waiver and Release of Liability, and Indemnification Agreement

I authorize the ALS Association to communicate with, obtain information from, and provide information to any service provider, including medical providers and insurance companies, for the purpose of discussing or arranging the services I request or need regarding the program.

In consideration of the ALS Association furnishing, discounts and grants for equipment or ALS medically related expenses and services prescribed or recommended by an ALS health care professional, as part of my participation in the program, I agree as follows:

ASSUMPTION OF RISK - I understand that my participation in the program contemplates the receipt of discounts and grants from the ALS Association that may be used for, but is not limited to, my receipt of services, use of equipment, or operation of a vehicle. I understand and acknowledge that: (a) risks and dangers exist in my receipt of services, use of equipment, or operation of a vehicle that derive from the discounts and grants provided to me by the ALS Association; (b) my receipt of services, use of equipment, or operation of a vehicle that derive from the discounts and grants provided to me by the ALS Association may result in injury or death either to me or a third party; (c) these risks and dangers may be caused by the actions, inaction or negligence of either me or a third party; and (d) there may be risks not known to me or not reasonably foreseeable.

WAIVER AND RELEASE OF LIABILITY - I forever release, discharge and acquit the ALS Association from any and all claims, demands, suits, or causes of action of any nature which I may have against the ALS Association for damages, costs, expenses, attorneys' fees, damages to or loss of property, or personal injury, or death or any other losses or damages whatsoever that arise out of any act, occurrence, or accident in any way connected with my participation in the program.

INDEMNIFICATION - I agree to defend, indemnify and hold harmless the ALS Association from and against any claims, demands, suits, or causes of action of any nature by any third party for damages, costs, expenses, attorneys' fees, damages to or loss of property, or personal injury, or death or any other losses or damages whatsoever that arise out of any act, occurrence, or accident in any way connected with my participation in the program.

MISCELLANEOUS - 

• I agree that this Agreement shall be interpreted and enforced in accordance with Florida law.
• I agree that if one or more paragraph(s) of this Agreement are ruled invalid or unenforceable, such invalidity or unenforceability
• shall not affect any other provision of the Agreement, which shall remain in full force and effect.
• I agree that each provision of this Agreement is intended to be severable. If any term or provision of this Agreement is illegal or invalid for any reason whatsoever, such illegality or invalidity shall not affect the validity or legality of the remainder of this Agreement.
• As used in this Agreement, I understand the term “I,” "me," or "my" shall include my heirs, personal representatives, assigns, and agents. I understand that this Agreement binds my heirs, personal representatives, assigns, and agents.
• As used in this Agreement, I understand the term “the ALS Association” shall mean the ALS Association, as well as the ALS Association's officers, trustees, employees, volunteers, agents, representatives, and affiliated organizations.
• As used in this Agreement, I understand that the singular shall include the plural and vice versa; the terms “and” and “or” shall be both conjunctive and disjunctive; and the term “including” means “including without limitation.

I have read the above and fully understand 1.) The purpose, procedures, requirements, and 2.) This assumption of risk, waiver and release of liability, and indemnification agreement. I understand that I am giving up substantial rights, including my right to sue the ALS Association, and its officers, trustees, employees, volunteers, agents, representatives, and affiliated organizations. I also understand that this agreement binds heirs, my personal representatives, assigns, agents, and me. I acknowledge that I am signing this agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of liability. I assert that my participation in the care assist program is voluntary and I knowingly assume all such risks.

This form is an application, not a survey. By clicking on the Submit button, you are applying for Communication Equipment Assistance and your application is being sent to The ALS Association.

For more information, please contact infoFL@als.org.