Rural Accommodations Consent Form

Accommodations Consent Form

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Legal Name*

First Middle Last

Email*

Rotation Information

Are you enrolled in the Longitudinal Integration Clerkship program at either UAlberta or UCalgary?*

Yes

Rotation Program*

Location*

Rotation start date*

Day

Month

Year

Rotation end date*

Day

Month

Year

Potential Guests

Please note: Only your immediate family members (partners and children) are permitted to stay in RhPAP Accommodations.

I will have a guest stay with me in my RhPAP Accommodation.*

Yes

Maybe

Name of guest*

First Last

Guest's relationship to you*

Approximate dates of stay*

I will have a second guest stay with me in my RhPAP Accommodation.*

Yes

Maybe

Name of guest*

First Last

Guest's relationship to you*

Approximate dates of stay*

I will have a third guest stay with me in my RhPAP Accommodation.*

Yes

Maybe

Name of guest*

First Last

Guest's relationship to you*

Approximate dates of stay*

I will have a fourth guest stay with me in my RhPAP Accommodation.*

Yes

Maybe

Name of guest*

First Last

Guest's relationship to you*

Approximate dates of stay*

Communications

If you haven't already done so, are you interested in subscribing to RhPAP's e-newsletters to keep informed on other RhPAP programs and services?

Yes

Please enter the email address at which you would like to receive RhPAP's e-newsletters if it is different than the one you provided earlier.

Release, Waiver of Liability and Assumption of Risk

PLEASE READ THE FOLLOWING CAREFULLY.

These conditions limit your legal rights.

In consideration of my being assigned and permitted use of accommodation provided through RhPAP (hereafter, the "Accommodation"), I hereby acknowledge and agree to the following terms:

Select boxes to agree to the following terms:*

I hereby agree to fully comply with Alberta's Rural Health Professions Action Plan's Rural Accommodation Policy and Accommodation Information & Regulations (the "Policies and Regulations") that are currently in place and as may be amended from time to time. (The Policy and Regulations can be found at rhpap.ca/accommodationdocs.)

Consent*

I recognize that due to the limited availability of accommodations, I may be asked to share the Accommodation to which I am assigned.*

Consent*

I agree to abide by the rules and regulations of the owner, landlord or property management company (collectively, the "Owners") of the Accommodation that I am occupying for the duration of my rural experience. (These rules and regulations were attached to the email in which you were provided with a link to this form.)*

Consent*

I further acknowledge and agree: (a) not to use the Accommodation for any purpose other than as residential premises, (b) not to lease the Accommodation to any other individual, and (c) only my immediate family members (defined as my current partner and children) may stay in the Accommodation.*

Consent*

I further agree to inform RhPAP in advance of any immediate family members who may be staying in the Accommodation (who have not already been identified earlier in this form) as per the expectations laid out in the Policies and Regulations.*

Consent*

I agree to promptly inform RhPAP of any accident or issue that causes or may reasonably be expected to cause damage to the Accommodation as well as any vandalism and any break or defect in any of the utility systems servicing the Accommodation.*

Consent*

I understand and agree that I may be held liable for any costs RhPAP may incur to repair or replace any damage or loss to the Accommodation or property within the Accommodation, whether such loss or damage occurs as a result of my actions or inactions or those of my family members, agents, or invitees.*

Consent*

If, at the end of my stay, the Accommodation is not clean, in good condition or in the condition that the Accommodation was provided to me and in which it is required to be maintained in accordance with RhPAP's Policies and Regulations, excepting only reasonable wear and tear, I acknowledge and agree that RhPAP may invoice me for the cost of cleaning, replacing or repairing any lost or damaged items, and I shall promptly pay for or reimburse RhPAP for such costs in accordance with the Policies and Regulations.*

Consent*

I acknowledge that I am responsible for obtaining insurance coverage for any personal property located in the Accommodation during my stay and agree that any personal property left in the accommodation upon the termination of my stay in the Accommodation will be deemed to be abandoned and that RhPAP may dispose of such abandoned property at its discretion.*

Consent*

I acknowledge and agree that no pets shall be permitted in the Accommodation.*

Consent*

I acknowledge and agree to notify RhPAP of any vacancy in my Accommodation longer than one week and understand that vacancy checks may be conducted during that time frame. (These vacancy checks are required for property insurance purposes.)*

By typing my name below, I acknowledge that I have read and understood the terms and conditions contained in the Policies and Regulations and hereby agree to be bound by the terms contained therein and as set out above.*

Consent to Collect, Use and Disclose Personal Information

PLEASE READ CAREFULLY.

Consent to Collect, Use and Disclose Personal Information*

The terms of this consent agreement govern the collection, use and disclosure of my personal information which I voluntarily submit to the Alberta Rural Physicians Action Plan, operating at Alberta's Rural Health Professions Action Plan ("RhPAP").

The Purpose of Collection, Use and Disclosure

I acknowledge and agree that RhPAP may collect, use and disclose my personal information for the purposes of providing and administering the Rural Accommodations Program, including (without limitation):

matching me with a specific accommodation;

arranging for my secure access to this accommodation;

addressing any damage to the property that occurs during my stay as per the the Policies and Regulations; and

short- and long-term evaluation of the Rural Accommodations Program.

Personal Information Subject to Consent

I acknowledge and understand that the personal information that will be collected, used and disclosed by RhPAP for the purposes of providing and administering the Rural Accommodations Program includes:

Demographic information, including legal name and email;

Rotation information; and

Information about potential guests.

Withdrawal of Consent

I understand that I may withdraw or vary the terms of my consent in writing or electronically at any time. However, I recognize that RhPAP may be unable to provide me with accommodation in the event that I withdraw or vary the terms of my consent and further acknowledge that RhPAP reserves the right to refuse to provide accommodation in such an event.

BY CHECKING THIS BOX, I acknowledge that I have read and understood the terms and conditions associated with the collection, use and disclosure of my personal information.*

By typing my name below, I hereby consent to the collection, use and disclosure of my personal information by RhPAP in the manner and for the purposes set out above.*

Waiver, Release and Indemnity Agreement

This section contains important information where you are asked to waive or give up certain legal rights and take on certain legal responsibilities.

PLEASE READ CAREFULLY.

Waiver, Release and Indemnity Agreement*

This agreement constitutes a waiver, release and indemnity in accordance with the following terms:

I agree to indemnify the Alberta Rural Physicians Action Plan, operating as Alberta's Rural Health Professions Action Plan ("RhPAP") and its employees, officers and directors from any and all damage or liabilities caused to the Accommodation during my stay excepting only reasonable wear and tear, regardless of the cause of such damage.

I hereby release and waive any and all claims against RhPAP and its employees, officers and directors in respect of any damage or loss of any kind, including (without limitation) damage or loss to personal property, personal injury and death whether in contract, tort, equity or however caused, which I may have or may acquire as a result of my use of Accommodation provided through the RhPAP Rural Accommodations Program, including (without limitation) damage, loss, injury and death caused by negligence on the part of RhPAP or its employees, officers and directors.

I confirm that I have obtained and hold proper and adequate tenant insurance. I agree to provide a copy of such insurance to RhPAP at their request to demonstrate such insurance coverage.

I agree to indemnify and save RhPAP harmless from and against any and all claims, costs and expenses RhPAP may incur or be found liable for, as a result of my use of Accommodation provided through the RhPAP Rural Accommodations Program, including (without limitation) costs, expenses and legal fees on a solicitor-client basis which RhPAP may incur in defending any claims or lawsuits that I, or anyone on my behalf, may bring against RhPAP or its employees, officers and directors.

BY CHECKING THIS BOX, I acknowledge that I have read and understood the terms and conditions contained within the Waiver, Release and Indemnity Agreement outlined above., and hereby agree to be bound by the terms contained therin and as set out above.*

Consent*

In the event of a breach of any of the above terms, I acknowledge and agree that RhPAP may, at any time and at its sole discretion, terminate my stay in and use of the Accommodation, upon which time, I agree to deliver vacant possession of the Accommodation to RhPAP.

By typing my name below, I acknowledge that I have read and understood the terms and conditions contained in this waiver, release and indemnity, and hereby agree to be bound by these terms and conditions.*

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Phone

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Continuing Professional Development

Accommodations Consent Form

Rotation Information

Potential Guests

Communications

Release, Waiver of Liability and Assumption of Risk

PLEASE READ THE FOLLOWING CAREFULLY.

Consent to Collect, Use and Disclose Personal Information

PLEASE READ CAREFULLY.

The Purpose of Collection, Use and Disclosure

Personal Information Subject to Consent

Withdrawal of Consent

Waiver, Release and Indemnity Agreement

PLEASE READ CAREFULLY.