Application for Door Opener - Technology for Living

This application is being submitted by*

Applicant/Representative

Referring Therapist of Applicant

Applicant is*

Already a member of Technology for Independent Living (TIL) or Youth Assistive Technology (YAT)

New applicant of Technology for Independent Living (TIL) or Youth Assistive Technology (YAT)

Please also complete the Technology for Independent Living (TIL) or Youth Assistive Technology (YAT) application form.

Applicant's Name*

First Last

Date of Birth*

MM/DD/YYYY

Applicant's Email*

Applicant's Current Residence

Facility Name (if applicable)

Address

Street Address City Postal Code

Applicant's Phone

Home Address - Location of Door (If different than above)

Street Address City Postal Code

Medical Information & Coverage

Medical Diagnosis*

Referring Therapist

Facility/Organization

Facility/Organization Address

If different than above.

Street Address City Postal Code

Therapist Phone

Therapist Phone Extension #

Therapist Email

Does applicant have ICBC/WCB Coverage?*

If you do have ICBC or WCB coverage, you must first apply to ICBC/WCB for door opener funding.

ICBC

WCB

None

Financial Information

Gross Family Income*

as recorded on your last tax return

Cash Savings in Bank*

Can you, or your family, contribute towards the cost of the door opener?*

Yes

No

Needs / Abilities Assessment

Following your application, a TIL representative may ask for a video of you entering/exiting your door to assist with assessment. We may also ask for photos of your door (internal/external) to assist the door opener company.

Will you be willing to provide such videos/pictures if asked?*

Yes

No

How do you currently enter and exit the door in question?*

Where, in your home, is the door in question located? (front door, back door, suite door, garage, etc)*

What is your living situation? (alone, with family, in an apartment, in a house, in a facility, etc)*

What alternatives to an automatic door opener have you considered? (smart door lock, modified door handle, etc)

*If you are deemed ineligible for a TIL door opener, a TIL representative will be in contact to assist you in finding an alternative solution to your door opener challenges.

Do you consent to being contacted by the TFL peer program regarding upcoming virtual and in-person peer events, projects, and other peer-related initiatives.*

Yes

No

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

I understand that, due to the complexities of having a door opener installed, along with required consent forms, there may be a delay in getting a door opener installed. A TIL representative will assist me in gathering all required information, but should my information change during the application process, I must immediately notify Technology For Living of the changes that affect my application.

I understand that only one door opener will be provided to me as part of the TIL Door Opener program.

I understand that if I should move residences, I will need to pay to have the door opener removed and installed in my new residence. (before applying, TIL recommends you reside in a home you foresee yourself living in for many years, as door opener moves can be expensive).

I understand that, after the one year warranty period, I am responsible for all door opener repair costs moving forward. (TIL does not cover costs associated with the repair of door openers) Also, I understand that warranty does not cover damage associated with neglect of the door opener...these costs would need to be covered by myself.

I understand that if I rent, lease, own a strata lot, or live in a facility, I must receive written approval from the building manager or strata council prior to door opener installation. (A TIL representative will guide you through the information required from building managers and strata councils.)

I consent to TIL sharing my contact information (name, telephone number, email and address) with the company that may be installing an automatic door and with an electrician who may be performing the electrical work to power the door. I agree to proceed prior to installation and to be contacted in association with this project when required.

I agree, after installation of the door opener (if approved), to provide TIL with a quote regarding the affect the automatic door opener has on my independence within my home. (pictures greatly appreciated)

I agree to the Terms and Conditions

Consent

The applicant understands that, due to the complexities of having a door opener installed, along with required consent forms, there may be a delay in getting a door opener installed. A TIL representative will assist them in gathering all required information, but should their information change during the application process, they must immediately notify Technology For Living of the changes that affect their application.

The applicant understands that only one door opener will be provided to them as part of the TIL Door Opener program.

The applicant understands that if they should move residences, they will need to pay to have the door opener removed and installed in their new residence. (before applying, TIL recommends they reside in a home they forsee themselves living in for many years, as door opener moves can be expensive).

The applicant understands that, after the one year warranty period, they are responsible for all door opener repair costs moving forward. (TIL does not cover costs associated with the repair of door openers) Also, they understands that warranty does not cover damage associated with neglect of the door opener...these costs would need to be covered by them.

They understand that if they rent, lease, own a strata lot, or live in a facility, they must receive written approval from the building manager or strata council prior to door opener installation. (A TIL representative will guide them through the information required from building managers and strata councils.)

They consent to TIL sharing their contact information (name, telephone number, email and address) with the company that may be installing an automatic door and with an electrician who may be performing the electrical work to power the door. They agree to proceed prior to installation and to be contacted in association with this project when required.

They agree, after installation of the door opener (if approved), to provide TIL with a quote regarding the affect the automatic door opener has on their independence within their home. (pictures greatly appreciated)

I confirm that I have discussed with the applicant, and they have agreed to, all terms and conditions outlined above

Phone

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