Application for TIL Services - Technology for Living

Company

This field is for validation purposes and should be left unchanged.

Please confirm the following applicant's information*

If eligible, check all 3 boxes below and click the 'Next' button.

I am age 19 or older

I have limited mobility due to a permanent physical disability

I am a resident of British Columbia

You must meet the 3 eligibility requirements above to apply. If you have any questions, or require assistance completing this application, please contact us directly at 1-604-326-0175.

You can also complete this application using the Printable application form (pdf).

This application is being submitted by*

Applicant

Alternate Contact of Applicant

Referring Therapist of Applicant

Applicant's Name*

First Last

Date of Birth*

MM/DD/YYYY

Email

Primary Phone*

Secondary Phone (Optional)

Applicant's Current Residence

Address*

Street Address City Postal Code

Is this a facility?

Yes

No

Facility Name

Medical Information & Coverage

Medical Diagnosis*

Onset/Reason

Referring Therapist

Therapist Email

Therapist Phone

Therapist Phone Extension #

Therapist Address

Facility/Organization Street Address City Postal Code

Does applicant have ICBC/WCB Coverage?*

ICBC

WCB

None

ICBC/WCB Claim#

Case Manager Name

Phone

Fax

Email

Applicant's Alternate Contact

A family member, partner, caregiver, friend, etc.

Alternate Contact Name*

Relation to Applicant*

Alternate Contact Phone*

Alternate Contact Email

Alternate Contact Home Address*

Street Address City Postal Code

Environmental Control and Home Automation

Does applicant have any environmental controls at present?*

Yes

No

Please describe your current environmental controls

Describe any smartphones, tablets, or smart home automation devices currently used by applicant

Secured Wi-Fi is required for some TIL services. Do you have access to Wi-Fi that requires a password?*

What devices does applicant want to control from bed and/or wheelchair?*

Describe barriers/challenges applicant faces when using these devices*

What technology, switches or switch placement will best assist the applicant?

If unknown, leave blank

Would you like to receive TFL's quarterly newsletter, the Balance, which includes PEER stories, program updates, and other helpful information for members?*

Yes

No

Consent*

The applicant authorizes the Technology for Independent Living program, and/or its representatives to release to or obtain from such agencies, individuals, medical centres or hospitals as are concerned with their medical rehabilitation, any and all pertinent information which may be necessary to assist in providing them with medical rehabilitation services.

The applicant declares that any information which has been provided in order for the Technology for Independent Living program to determine their eligibility to receive services at no cost, or at reduced cost, is true to the best of their knowledge and belief.

The applicant understands that all such information will be treated as confidential and privileged, and used only for the purpose of assisting their medical rehabilitation.

The applicant is nineteen years of age or older.

The applicant understands that, upon their approval for assistance from Technology for Independent Living, they will automatically become a member of Technology for Living.

Liability Disclaimer and Member Responsibilities
By accepting and using any device provided by Technology for Living (“TFL”), the member agrees to the following terms:

1. Proper Use
o The member agrees to use the TFL-provided device solely for its intended purpose and in accordance with any instructions, guidelines, or training provided by TFL.

1. Prohibited Uses
o The member shall not use the device in any emergency situations where failure of the device may result in harm, injury, or death.
o The member shall not modify, tamper with, or alter the device in any way.
o The member shall not use the device in any manner that is unsafe, illegal, or contrary to the intended purpose of the device.

1. Limitation of Liability
o TFL is not responsible for any harm, injury, disability, death, or loss of any kind resulting from the misuse, modification, or inappropriate use of the device by the member.
o TFL does not guarantee that the device will function in all situations or that it will prevent any harm or injury.
o The member acknowledges and accepts all risks associated with the use of the device.

1. No Legal Recourse Against TFL
o The member, their heirs, representatives, or assigns shall not hold TFL, its staff, affiliates, or partners liable for any direct, indirect, incidental, consequential, or special damages arising from the use or misuse of the device.

1. Indemnification
o The member agrees to indemnify and hold harmless TFL from any claims, demands, liabilities, damages, or expenses (including legal fees) arising from their use of the device in a manner not in compliance with these terms.

By checking this box I confirm that I have discussed with the applicant, and they have agreed to, all terms and conditions outlined above.