Participant Form -- Project Open House

DISABLED PERSON'S NAME: _______________________________________________

HOMEOWNER'S NAME: ____________________________________________________

TELEPHONE: ________________________________________ DATE: _____________

I __________________________________________________ give my consent to Shirley Eves Developmental and Therapeutic Center to make the following alterations, installations and improvements on the above named dwelling, on my behalf as the resident there within. These alterations are subject to approval and revision by Shirley Eves Developmental and Therapeutic Center. This is not a contract and is not binding. Services will be provided within the terms of the "Community Contract" between Shirley Eves Developmental and Therapeutic Center and the participant.

The alterations made are for the temporary use of the participant and cannot be altered in any way or destroyed. Once the need of the participant ends or the participants no longer lives in the dwelling, the Center shall reclaim the alterations for use by another deserving individual. If the participant destroys or damages the alterations, he shall be obligated to repair or replace them at his own expense. The participant and the Center agree that the alterations can be reclaimed at the sole discretion of the Center.

The participant hereby agrees to release and hold harmless the Shirley Eves Developmental and Therapeutic Center, its agents and employees from any and all claims, risk of loss, damage or liability incurred in connection with the alteration or improvement to the above noted dwelling by the Shirley Eves Developmental and Therapeutic Center and/or its subcontractors.

PARTICIPANT

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Signature

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