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CIL's in TN
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Home
About US
Services
Family Support
Services
Resources
CIL's in TN
Donate
Contact Us
T.A.R.P. Center
Equipment Loan Program
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Indicates required field
Name
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First
Last
County of Residence
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Date Begun
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Target Date
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COVID Related?
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Yes
No
Situation
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Equipment Goal
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Steps
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Equipment Received
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Choose One
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New
Used
Item Number
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Equipment Received
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Choose One
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New
Used
Item Number
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Equipment Received
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Choose One
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New
Used
Item Number
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If any of the items are a wheelchair please specify size below (18", 20", Bariatric size if known)
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How will this help me?
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I was directly involved in the development of this Independent Living Plan and agree to
participate in these services. I understand that I am not legally bound as a contract but I
affirm that I am committed to work toward achieving these goals and hope to achieve the
first goal by:
Goal Date
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Approval or Waiver of Independent Living Plan
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I accept the Independent Living Plan outlined above. I will work alone or with my ILS toward my goals.
I waive the right to establish an Independent Living Plan. I choose to develop my goals on my own and will seek advocacy when I feel it is needed.
I have recieved equipment and have been trained with proper care and use of the item
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Yes
I have recieved a copy of the release form
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Yes
RELEASE FORM IS FOUND HERE
Todays Date
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By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this form
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I Accept
Any request for services or equipment is subject to approval and availability.
Upon approval you will be notified.
ILS Signature
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Date
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Submit