Signature Authority Each party has the full power and authority to enter into and perform this Agreement, and the person signing this Agreement on behalf of each Party has been properly authority and empowered to enter into this Agreement.
Signature Signature For the participant For the institution Xxxxxx Xxxxx prof. Ing. arch. Xxxxxx Xxxxxxx, PhD. Vice-xxxxxx for International Relations and Public Relations, based on the procuration Annex I
Legal Signature This Agreement may be executed and delivered by any party herein by sending a facsimile of the signature or by a legally recognized digital or electronic signature. Such legal signature shall be binding on the party so executing it upon receipt of signature by the other party.
Preparer’s Signature The person completing the DBE commitment form on behalf of the consultant’s firm must sign their name.
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.
Authority of Signatories The individuals executing this Agreement represent and warrant that they have the authority to sign on behalf of their respective parties.
Counterpart Signatures For the purpose of facilitating the recordation of this Agreement as herein provided and for other purposes, this Agreement may be executed simultaneously in any number of counterparts, each of which counterparts shall be deemed to be an original, and such counterparts shall constitute but one and the same instrument.
Authority of Signatory Each signatory below represents and warrants that he or she has full power and is duly authorized by their respective party to enter into and perform this Contract. Such signatory also represents that he or she has fully reviewed and understands the above conditions and intends to fully abide by the conditions and terms of this Contract as stated.
Counterpart Signature This Agreement may be signed in counterpart, and the signed copies will, when attached, constitute an original Agreement.
