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Parent Name*
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Section A: Qualifications For Service

The Singletons provides free services to single parents undergoing treatment for cancer.

To qualify, participants must:
  • Provide treatment information including a signed document from the consulting doctor
  • Be living a single lifestyle with no significant other living in the home
  • Have child(ren) under 18 years old and in custody of parent living in the same home as participant at least 50% of the time
  • In need of financial or household assistance
  • Must be recovering from a cancer related surgery (not including reconstructive), actively receiving chemotherapy, radiation or related cancer treatment that affects your ability to work or maintain the household

Current Household Demographics

Please initial to verify that you qualify for The Singletons’ services.
It is our goal to help as many parents that qualify for services as possible. As a non-profit organization, our resources are solely based on community support and are limited. The Singletons reserves the right to refuse service to any party that the Executive Director, Program Manager or Board of Directors of The Singletons finds is not in the best interest of the organization without providing a reason to the participant for doing so. The Singletons reserves the right to modify, terminate, suspend or reduce any of our programs, financial support amounts, duration of support, number of participants, or qualification requirements without prior notice and without seeking the consent of participants.

The Singletons must be immediately informed by phone if any of these qualifications can no longer be met at any point while receiving services. Failure to notify The Singletons of a change in eligibility constitutes immediate removal from services provided and the ineligibility of any future services.

Section B: Release Of Liability

I freely choose to accept the assistance that will be provided to me by The Singletons. I understand that some of the individuals participating in providing assistance to The Singletons are volunteers. I give permission to the volunteers of The Singletons to provide me with the assistance and care they are assigned. Neither the volunteers, employees, or The Singletons itself are liable for any risk and/ or injury that may occur to me and/ or dependents through the volunteer process or services provided.

I HEREBY WAIVE AND RELEASE, indemnify, hold harmless and forever discharge The Singletons and its agents, employees, officers, directors, volunteers, affiliates, successors and assigns, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities, of every kind and nature, whether known or unknown, in law or equity, that I ever had or may have, arising from or in any way related to my participation in any of the events or activities conducted by, services received, on the premises of, or for the benefit of, The Singletons provided that this waiver of liability does not apply to any acts of gross negligence, or intentional, willful or wanton misconduct.

By this Waiver, I assume any risk, and take full responsibility and waive any claims of personal injury, death or damage to personal property, including but not limited to any volunteer activities, house cleanings, yard cleanings, meals provided, kids’ events or other services provided by The Singletons.

The provision of this SERVICE AGREEMENT will continue in full force and effect even after the termination of the activities conducted or services provided by, or for the benefit of The Singletons whether by agreement, by operation of law, or otherwise.

I have read, understand and fully agree to the terms of this SERVICE AGREEMENT. I understand and confirm that by signing this SERVICE AGREEMENT I have given up considerable future legal rights. I have signed this Agreement freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to me. My signature is proof of my intention to execute a complete and unconditional SERVICE AGREEMENT of all liability to the full extent of the law. I am 18 year of age or older and mentally competent to enter into this waiver.

We encourage you to discuss with us any questions you may have concerning these policies and procedures prior to signing this document.

Photography and Video Release:

I grant The Singletons, its representatives and employees the right to take photographs or video of me and my dependents. I authorize The Singletons, its assigns and transferees to copyright, use, and publish, the same in print and/or electronically.

I agree that The Singletons may use such photographs or video of me and my dependents with or without my first name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Release of Personal Information

The Singletons at times shares personal information such as the first name and children's first names, part of town domiciled, the type of cancer and health condition of the parent. For cleaning events, once volunteers have registered, they will be provided with your home address to attend the event. Examples of when this information may be shared with outside parties includes: recognition in newspaper, newsletters, websites, marketing material, news segments and other various media. Beyond the Client Care Coordinator, staff of The Singletons and the Executive Director, last names are not used for service recipients.

Events & Transportation

I do hereby give permission for myself and minor children to participate in any and all Singleton Kids events and programs. I release The Singletons, and any of its representatives, whether paid staff or volunteer from any and all liability, as I understand these events may entail a certain level of risk.

In the infrequent event that myself and/or my child would need transportation by The Singletons, I fully recognize that such an undertaking involves an element of risk, I assume all risks and hazards incidental to such participation and do hereby release, absolve, indemnify, and agree to hold harmless The Singletons, its representatives, whether paid staff or volunteer, from financial responsibility for any injury, illness or death as a direct or indirect result of this activity.

3rd Party Donations

On the occasion that The Singletons receives a On the occasion that The Singletons receives a donation from a 3rd party, these are available to The Singletons’ families on a first come, first served basis. The Singletons is not responsible for the condition/state of donation item. If a Singleton Family is unhappy with the state of the donation, they do not have the right to contact the donor. Neither will The Singletons be responsible for removing of items decidedly unwanted from the family.

Section C: Signature

I indicate that by my signature below I have read the terms and conditions of the assistance offered and agree to abide by them. I have carefully read this SERVICE AGREEMENT.

I acknowledge that I understand the SERVICE AGREEMENT, its Release of Liability contents and confirm that all Qualifications have been met.

The SERVICE AGREEMENT shall be governed by the laws of the State of Arizona which shall be the forum for any lawsuits filed under or incident to this SERVICE AGREEMENT or in regards to The Singletons. If any portion of this SERVICE AGREEMENT is held invalid, the rest of the document shall continue in full force and effect.
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Consent*
Updated: 02/24/2022
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