Children's Assistive Technology Service (CATS)

Disclaimer

Equipment Release for

Children’s Assistive Technology Service

Serving Children in Virginia

 

 

DATE________________________   This release pertains to equipment donated by Children’s Assistive Technology Service (CATS) to the Recipient.  The Recipient is PARENT or LEGAL GUARDIAN of

(child’s name)________________________who resides at

__________________________________________________________________________

__________________________________________________________________________

Family’s phone number and/or email address:________________________________________

EQUIPMENT

Item code number_____________________________________________________________

Description__________________________________________________________________

Accessories__________________________________________________________________

Please read all the conditions before signing the Equipment Release Form.  As the recipient for

(child’s name) ________________________________________________________________

and acting on his/her behalf, I understand and agree that:

  • The durable medical equipment I am receiving is a non-prescriptive device and is free of charge.
  • CATS does not warrant in any way the condition of the equipment.
  • I understand that the suitability and the fit of the equipment is to be determined by the user’s personal physician or physical therapist and that CATS does not warrant that the equipment is safe or suitable for the child named above.
  • I agree to inspect the equipment and understand that the equipment may need sanitization and is likely to require adjustment to best suit my child.
  • I am responsible for following up on the manufacturer’s original warranty, if there is one.
  • I am responsible for checking to see if the equipment has been recalled by the FDA by going to the website: http://www.fda.gov/MedicalDevices/Safety/ListofRecalls/ucm384921.htm
  • I am responsible for any repair or maintenance of the equipment that may be necessary.

I hereby release and hold harmless CATS, its personnel, and all persons acting on their behalf from any and all claims by me or my child, or any person(s) acting on my behalf or my child’s behalf for any loss, personal injury, liability, expense or damage, including, but not limited to general, specific, incidental, or consequential damages of any kind or nature whatsoever arising from the receipt of this equipment or its use.

Print name______________________________________________________

 

Signature_______________________________________________________

 

Relationship to child______________________________________________

 

Date___________________________________________________________