Witness Signature 4. PARENT/GUARDIAN CONSENT: (for applicants under 18 years) – I hereby certify and decree that all the information contained in the declarations above is true and accurate Print Name:................................................................... Signature …………………………………………....……... Relationship to applicant ……………………………… Phone Contact ……………………................................... Address …………………………………………………………………….....................................................................
AGREEMENT SIGNATURES By signing below, both parties agree to the terms and conditions of this Agreement. Please acknowledge acceptance of this document and terms by returning a signed copy within seven (7) days of issuing. If a signed copy is not returned within seven (7) days and you are attending service, Fighting Chance will deem this to be acceptance of the document. If signed by Xxx XxxXxxxxxxX: Signature of Participant: Date: If signed by Person Responsible: I confirm that this Agreement has been explained to the individual receiving the services and that they agree to the terms. I further confirm that I have authority to sign on their behalf. Signature of Person Responsible: Date: SignaĒure on behalf of FighĒing Chance: Signature of Person(s) responsible: Date: Name: Appendix 1 Key Contact Details Participant’s Name Participant’s Email Participant’s Phone Participant’s Address Person(s) responsible’s Name Person(s) responsible Relationship to Participant Person(s) responsible’s Email Person(s) responsible’s Phone Support Coordinator (where applicable) Support Coordinator’s Name Support Coordinator’s Email Support Coordinator’s Phone Shared Living/Supported Accommodation/Group Home (if applicable) House Manager’s Name House Manager’s Email House Manager’s Phone Additional Contacts (if applicable) Role Contact’s Name Contact’s Email Contact’s Phone Appendix 2 NDIS Claiming Preferences Fighting Chance supports NDIS participants who are NDIA-Managed, Self-Managed or Plan Managed. To invoice and bill you correctly, it is important you keep us updated with your plan management preferences, and let us know ongoing if your status changes. For the purposes of services delivered by Fighting Chance, your NDIS plan is: (please tick) ☐ NDIA-MANAGED You understand that Fighting Chance will claim directly through the NDIA portal if your funding for Fighting Chance is NDIA-managed, so you will not receive any direct request for payment from us. To ensure that you do not get a text from the NDIA to approve each claim weekly, endorse Fighting Chance as a ‘My Provider’ for automatic payment processing. Instructions can be found at xxxxxxxxxxxxx.xxx.xx/xxxx/ or you can contact the Fighting Chance My Provider Endorsement Helpdesk on (00) 0000 0000 or xxxxxxxxxxxxxxx@xxxxxxxxxxxxx.xxx.xx ☐ (Optional) Please supply me, by email, with monthly Statements of Account to: ☐ SELF-MANAGED ☐ I am self-managed and would like to be invoiced for services once a week. Please email invoices to: Please see Appendix 3 for Self-Management Payment Options. ☐ PLAN-MANAGED Please send invoices to my plan manager: Plan management organisatio Contact Name Email Address Phone number ☐ OTHER FUNDING (eg. self-funded, iCare or other insurance funding) Please email invoices to: Appendix 3 Self-Managed Payment Options Participants who are self-managed have a number of payment options with Fighting Chance: ☐ DIRECT DEPOSIT (preferred option) Payment of Fighting Chance invoices can be made by Electronic Funds Transfer (EFT) through your bank. Fighting Chance’s bank account details are as follows: Bank: Commonwealth Bank of Australia Account Name: Fighting Chance Australia Ltd BSB: 062-438 Account Number: 00000000 To ensure all payments are correctly allocated to your account, please include the full invoice number in the reference field. ☐ CREDIT CARD Payments can be made by credit card by clicking the ‘pay by credit card’ link included on the invoice. Please note that a service fee for this option will be imposed. ☐ PAYPAL Payment of your invoices can also be made via our PayPal account. To make payment via PayPal, please access the following link: xxxxx://xxxxxx.xx/FightingChanceAus?locale.x=en_AU To ensure your payment is correctly allocated, please enter the full invoice number in the reference field. Appendix 4 Non Face to Face Time Breakdown - Jigsaw Standard Non Face-to-Face Supports Delivered to every Jigsaw Participant daily, weekly, annually Writing the Board (i.e. preparing and writing up each person’s individualised program for the following day). Reviewing Trainee records/journal notes/medical or other key information to be able to best support the person during their day. Parent/Guardian/Carer Updates, i.e. emails, phone calls. Pre- and post-shift sta briefings. Zone setup (setting up workstations, boxes, visuals and group training areas) Resource development to support each Trainee to progress towards their employment goals (adapting training resources, creating visual aids and cheat sheets, etc). Research/Coordination to implement support strategies (disability, behavioural and learning strategies). Family reviews and the development of training plans (planning, delivery and follow up). Planning social events and extra curricular training (e.g. TAFE). Standard NDIS Annual Support Review Letter. Standard Ǫuarterly Reports - Upon Request. Complex Non Face-to-Face Supports - Delivered to Jigsaw Participants with High Intensity Support Needs (in addition to supports outlined in Standard) Allied health meetings, phone calls, correspondence. Specialist/additional sta training (internal or external), i.e. BSP implementation training. Creation of additional/detailed social stories/visuals. Data collection requested by behaviour therapists. Incident follow up or crisis meetings (seperate to regular family updates or regular allied health meetings). Development/review/discussion of medication forms/transfer plans/mealtime assistance plans etc. Detailed and regular sta training on individual complex behaviour/medical/transfer/mealtime support plans. Extended daily pre-brief and debrief. Additional Non Face-to-Face Supports - billed separately upon request Detailed NDIS Review Letters One-o engagement or training with Allied Health. Detailed Ǫuarterly Reports.
Contract Signature If the Original Form of Contract is not returned to the Contract Officer (as identified in Section 4) duly completed, signed and dated on behalf of the Supplier within 30 days of the date of signature on behalf of DFID, DFID will be entitled, at its sole discretion, to declare this Contract void. No payment will be made to the Supplier under this Contract until a copy of the Form of Contract, signed on behalf of the Supplier, is returned to the Contract Officer.
DRUG ABUSE DETECTION AND DETERRENCE 2.18.1 It is the policy of the City to achieve a drug-free workforce and workplace. The manufacture, distribution, dispensation, possession, sale, or use of illegal drugs or alcohol by contractors while on City Premises is prohibited. Contractor shall comply with all the requirements and procedures set forth in the Mayor’s Drug Abuse Detection and Deterrence Procedures for Contractors, Executive Order No. 1-31 (the “Executive Order”), which is incorporated into this Agreement and is on file in the City Secretary’s Office.
Student Signature By signing this contract, Resident agrees to pay the contract amount (room, board and association fees) in accordance with Addendum B: Rate and Payment Schedule. Resident may pay the full amount due prior to the due date, at the Resident’s election.
Electronic Note Signed with Xxxxxxxx’s Electronic Signature If the Note evidencing the debt for this Loan is electronic, Borrower acknowledges and represents to Lender that Borrower: (a) expressly consented and intended to sign the electronic Note using an Electronic Signature adopted by Xxxxxxxx (“Borrower’s Electronic Signature”) instead of signing a paper Note with Xxxxxxxx’s written pen and ink signature; (b) did not withdraw Xxxxxxxx’s express consent to sign the electronic Note using Borrower’s Electronic Signature; (c) understood that by signing the electronic Note using Xxxxxxxx’s Electronic Signature, Xxxxxxxx promised to pay the debt evidenced by the electronic Note in accordance with its terms; and (d) signed the electronic Note with Xxxxxxxx’s Electronic Signature with the intent and understanding that by doing so, Borrower promised to pay the debt evidenced by the electronic Note in accordance with its terms. NON-UNIFORM COVENANTS. Xxxxxxxx and Xxxxxx further covenant and agree as follows:
Electronic and Digital Signatures The parties to this Agreement agree that any electronic and/or digital signatures of the parties included in this Agreement are intended to authenticate this writing and to have the same force and effect as the use of manual signatures.
Agreement to Use Electronic Signatures I agree, and it is my intent, to sign this Contract by accessing State of Indiana Supplier Portal using the secure password assigned to me and by electronically submitting this Contract to the State of Indiana. I understand that my signing and submitting this Contract in this fashion is the legal equivalent of having placed my handwritten signature on the submitted Contract and this affirmation. I understand and agree that by electronically signing and submitting this Contract in this fashion I am affirming to the truth of the information contained therein. I understand that this Contract will not become binding on the State until it has been approved by the Department of Administration, the State Budget Agency, and the Office of the Attorney General, which approvals will be posted on the Active Contracts Database: xxxxx://xx00.xxxx.xx.xxx/psp/pa91prd/EMPLOYEE/EMPL/h/?tab=PAPP_GUEST In Witness Whereof, Contractor and the State have, through their duly authorized representatives, entered into this Contract. The parties, having read and understood the foregoing terms of this Contract, do by their respective signatures dated below agree to the terms thereof. [Contractor] [Indiana Agency] By: By: Title: Title: Date: Date: Electronically Approved by: Department of Administration By: (for) Xxxxxx X. Xxxxx, Commissioner Refer to Electronic Approval History found after the final page of the Executed Contract for details. Electronically Approved by: State Budget Agency By: (for) Xxxxx X.Xxxxxx, Director Refer to Electronic Approval History found after the final page of the Executed Contract for details. Electronically Approved as to Form and Legality: Office of the Attorney General By: (for) Xxxxxx X. Xxxx, Xx., Attorney General Refer to Electronic Approval History found after the final page of the Executed Contract for details.
Smoke Detector Tenant acknowledges that Premises is equipped with a smoke detector(s) that is in good working order and repair. Tenant agrees to be solely responsible to check the smoke detector every thirty (30) days and notify Landlord immediately if the smoke detector is not functioning properly.
INITIALS GMO". The Manager owns the initials "GMO" which may be used by the Trust only with the consent of the Manager. The Manager consents to the use by the Trust of the name "GMO Trust" or any other name embodying the initials "GMO", in such forms as the Manager shall in writing approve, but only on condition and so long as (i) this Contract shall remain in full force and (ii) the Trust shall fully perform, fulfill and comply with all provisions of this Contract expressed herein to be performed, fulfilled or complied with by it. No such name shall be used by the Trust at any time or in any place or for any purposes or under any conditions except as in this section provided. The foregoing authorization by the Manager to the Trust to use said initials as part of a business or name is not exclusive of the right of the Manager itself to use, or to authorize others to use, the same; the Trust acknowledges and agrees that as between the Manager and the Trust, the Manager has the exclusive right so to authorize others to use the same; the Trust acknowledges and agrees that as between the Manager and the Trust, the Manager has the exclusive right so to use, or authorize others to use, said initials and the Trust agrees to take such action as may reasonably be requested by the Manager to give full effect to the provisions of this section (including, without limitation, consenting to such use of said initials). Without limiting the generality of the foregoing, the Trust agrees that, upon any termination of this Contract by either party or upon the violation of any of its provisions by the Trust, the Trust will, at the request of the Manager made within six months after the Manager has knowledge of such termination or violation, use its best efforts to change the name of the Trust so as to eliminate all reference, if any, to the initials "GMO" and will not thereafter transact any business in a name containing the initials "GMO" in any form or combination whatsoever, or designate itself as the same entity as or successor to an entity of such name, or otherwise use the initials "GMO" or any other reference to the Manager. Such covenants on the part of the Trust shall be binding upon it, its trustees, officers, stockholders, creditors and all other persons claiming under or through it.
