Assistive Devices Loan Application

Requests for equipment are to be submitted by an Occupational Therapist or Physiotherapist.

 

Note:

  • Easter Seals Nova Scotia does not guarantee the condition of the equipment provided
  • Equipment provided and any ongoing maintenance becomes the sole responsibility of the recipient and/or family or guardian
  • Equipment may be donated back to the Easter Seals Assistive Devices Equipment Program; however, acceptance of equipment is based on space availability at the time of request.
  • Equipment is first provided to completed applications by the date received
  • Although we strive to keep our inventory accurate, no item is guaranteed until confirmed by Easter Seals Nova Scotia

 

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Department of Community Services client:
Is the client in or waiting placement for in a long-term care facility?

Client/Borrower Acknowledgment and Waiver – Read carefully before signing

If your application is accepted, the equipment noted on this form will be provided to you by Easter Seals Nova Scotia as part of the services provided under the Easter Seals Nova Scotia Assistive Devices Equipment Program. Your signature below acknowledges that you will seek instruction in the use of the equipment if/when appropriate and that you will comply with any use and safety guidelines that may be associated with the equipment. Easter Seals Nova is not responsible for injuries or damage incurred during the use of the equipment. By completing this application you agree to accept any risk that may be associated with the use or operation of the refurbished equipment provided. You also agree to waive any right you may have to claim against Easter Seals Nova Scotia, its officers, directors, affiliates, agents and employees for any injury, loss or damage that may arise out of your possession, use or operation of the equipment. administration of providing equipment
Signature of Client/ Borrower
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Therapist Signature
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