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By inserting the first and last initials of the name of the individual completing the application and the name of the patient (if not the applicant), he/she/they are: 1) providing the required acknowledgments as well as disclaimers and 2) agreeing and consenting to all of the below terms and conditions:

I/We have read the FAQs and entire application, understand it, and have completed and signed it freely, willingly and voluntarily. If the patient is under 18 years of age, a parent/legal guardian has initialed here and below.

I/We understand and agree that an application is not deemed complete and will not be reviewed by the Board of Directors and Respite Committee until A Week Away (in its sole discretion) has received all information requested including but not limited to all supporting materials/documentation.

I/We understand and agree the patient must meet certain eligibility criteria as established by A Week Away, understand the specific criteria, and have completed this application with the direct knowledge of that criteria.

I/We understand and agree that A Week Away, and its board members, reserve the right at any point during the application and approval process and at its sole discretion to refrain from approving the respite, and that completion of this Application and then approval does not guarantee patient will receive a respite.

I/We understand and agree that A Week Away is not required to offer or provide expenses related to the trip, including but not limited to lodging, transportation, incidentals and opportunity costs (as defined by A Week Away) and by initialing here, I/We agree that financial records are being provided willingly and voluntarily to A Week Away.

I/We certify that all information provided in this is true to the best of our knowledge and I/We will contact A Week Away if the application must be supplemented or modified.

I/We understand the risks associated with taking a respite, which requires travel and taking the patient away from his/her medical team and acknowledge and agree that if the patient is unable medically to take this respite, he/she should refrain from traveling away from his/her medical team.

I/We agree that A Week Away has not made any promises or representations regarding the trip location, the safety of the location or the availability of medical care providers in or around the location.

I/We agree that the application is only being considered relative to the patient and the respite cannot be assigned to someone else if approved by A Week Away.

I/We understand that if approved, I/We could be required to provide additional information to A Week Away and execute additional documentation/legally binding materials relative to the patient (including but not limited to medical clearance by patient’s current treating physician) and the respite, and patient authorizes A Week Away to contact and speak with the applicant at any time during the application process and thereafter.