By providing your electronic signature below, you are agreeing to the following:

I hereby authorize The ALS Association to release the above information to the contracted home care agency designated to provide services (up to 18 hrs/month) to my family. I understand that fees are negotiated on my behalf, and that billing will be sent to The ALS Association. The ALS Association, and its employees, directors, contractors and agents are released from any and all claims, asserted liability, or actual liability related to or associated with respite care funded by The ALS Association for my family, including, without limitation, any caregiver training provided by The ALS Association and all determinations of need or other determinations of qualification for the Jack Norton Caregiver Respite Program.