HomeMy WebLinkAbout1/16/2013 - STAFF REPORTS - 00 1/16/13
DepotSynthetic Grass
Therna Johannsen
760.485. 1381
City of Palm Springs
Office of
T —irn Buyback Program Grants
• Landscaping materials including rock, stones,
decomposed granite and other permeable landscaping
materials (Synthetic Grass Qualifies)
♦ Pervious paving (Synthetic Grass Qualifies)
• Other approved landscaping with native plant materials
and permeable ground cover or landscape surface
material (Synthetic Grass Qualifies)
�uB.�✓e �mm�
1/16/13
Asking The City of Palm Springs
synthetic grass and include it as part of the
Lawn Buyback Program.
• Todays synthetic grasses are manufactured following US regulations on
consumer safety with wide array of applications.
• All Poly blades and Urethane backing meet and exceed CPA guidelines.
• There is a desire for desert landscape to work in tandem with synthetic grass
for a beautiful and conservation minded community.
• Even a small amount can make an esthetic and pleasing area
Safe and clean for children to play on
Ideal product for a family recreational area
4 Pet friendly and tolerant
What I knowabout todays
All Poly fibers and urethane backing
As safe as pavers.rock or concrete and a lot more fun!
• Does not kill worms and bugs in the soil
• There are no VOC's-No metal contaminants
♦ The ground below the turf remains so alive weeds continue to grow up
through the turf!
• Pesticide and fertilizer reduction for ground water and family safety
• Drainage holes spaced 3" apart mimic natural percolation of rainwater
♦ Helps control erosion when used on hillsides
• Natural fire deterrent-will not catch fire
♦ Controls both mud and dust—no muddy paws and no indoor dust
2
1/16/13
Polypropylene/Polyethylene
: .d
• Corrosive resistant, non toxic, strong, safe,versatile and recyclable
o Long and short strands are bundled together in carpets,clothing
and acoustic insulation
Leading choice for medical materials.Mesh used to repair hernias,
internal walls of several organs and for sutures and stiches.
• Chemically inert and most produced plastic in the world
• Used in food and non food packaging
• Water bottles, liners for milk and juice cartons
• Household goods,toys, sports equipment, marine craft and
airplanes
Polyurethane
:.
94
• Began in aircraft manufacturing-now part of our modern life
• Ideal for flexibility, heat resistant and durable
• Surgical tubing, catheters, drapes, car seats, insulation,footwear,baby
toys and airplane wings
• Works well as a protective coating for furniture and a glue for industrial
and consumer products
• Resists moisture and heat and protects from rot, corrosion and fading
3
1/16/13
What about lead?
• Todays synthetic grasses made in the USA do not contain lead
• Old Nylon bladed turf was dyed with paint to be green. It was
this dye that contained the lead.
♦ Todays Poly blades are not dyed with paint. They are
extruded in green shades and do not contain lead.
♦ Lead concerns arise only when crumb rubber is used for infill.
4
PALM SPRINGS CITY COUNCIL
UPDATE ON THE
SECOND ANNUAL
Pal Srings
FINE AtFIT FAIR
post-war and contemporary art
February 14 - 17, 2013
Palm Springs Convention Center
- .
Y ,
STATUS.
❖ The Fair is expanding to 55 galleries,up from 50 in 2012.We're now
international with galleries coming from London,Vancouver and Barcelona.
❖ The Fair features contemporary and post-war art,blue chip to emerging.
Visitors will see local artists featured alongside names such as Andrew
Wyeth, David Hockney,Wayne Thiebaud,Andy Warhol, Robert Irwin and
Jenny Holzer.Participating Coachella Valley galleries are Michael Lord,
Imago, Heather James,Christian Hohmann, Izen Miller and Melissa Morgan
Fine Art.
❖ Our inaugural event last year had 9,500 attendees and we're projecting
12,000 for next month. Last year's attendees came from across the US,but
especially Los Angeles, Orange County,San Francisco,San Diego, Phoenix and
Scottsdale.This is a high net worth audience. One of our attendees purchased
a house during his visit.
❖ We've expanded our footprint for 2013 by establishing cultural partnerships
with more than 60 organizations in the Southwest,from California to New
Mexico.These prestigious museums and arts groups have committed to bring
their donors and trustees.
❖ Our Opening Preview Party on Valentine's Day will honor Mrs. Helene Galen
for her gift to the Palm Springs Art Museum.A painting by 60s icon Mel
Ramos will be auctioned off to benefit the Museum,and a cheeky"edible
installation"will celebrate the pop sensibility of Mr. Ramos.
❖ The Fair is honoring Mr. Ramos with a Lifetime Achievement Award,and will
display a 50 year retrospective of his work.
❖ The Fair and the desert art scene were prominently featured in the
January/February edition of Art Ltd. Magazine,with an article by Palm
Springs Life editor Steven Biller.Steven has recruited a stellar Host
Committee, including Councilmember Lewin.
❖ We are donating$8,750 in complimentary tickets to the City. Day passes will
also be available in copies of Palm Springs Life,through the Museum,Visitors
Centers and local hotels.
❖ We are partnering with the City to promote the 75th Anniversary.We have
included the commemorative logo on our website, catalog and eblasts.We're
also exploring ways to partner with the Public Art Commission to welcome
air travel passengers to the City and the Fair.
DOC # 201 10284566
06/20/2012 11:46A Fee:21.00
Page 1 of 3
RECORDING REQUESTED BY: Recorded In Official Records
STEWART TITLE OF CALIFORNIA, INC. County of Riverside
Larry W. Ward
Assessor, County Clerk & Recorder
^�WHEN RECORDED MAIL TO: IIII I IIIIIII IIII)IIII IIII(IIII IIIII(I IIII IIII IIII
,-'14 i2 �h�iVm S R I U I PAGE SIZE DA ;M1,9CONG RFD COPY
ORDER NO. M A- L 466426 PCOR SMFESCROW NO. T: CTY
UNIFORM STATUTORY FORM POWER OF ATTORNEY 24
(California Probate Code Sec. 4401) >309
NOTICE- THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. THEY ARE EXPLAINED
IN THE UNIFORM STATUTORY FORM POWER OF ATTORNEY ACT(CALIFORNIA CIVIL CODE SECTIONS 4400-
4465, INCLUSIVE). IF YOU HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL
ADVICE. THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL AND OTHER HEALTH-CARE
DECISIONS FOR YOU. YOU MAY REVOKE THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO.
! T1\0NA5 Allen 00%eyhy
3`4 3'1 EAST Ca-Ue i#3 ?&IA s rrJ'„ i CA 922(.14
your ame a dre
appoint Q-Mmo n
01li a6mfig- I^1L1 YaAe. V_"r;'ae Ro",_, o Airayei U 42210
name one atioress ot me person appointed,or ot eaw person appointed you want to designate more an one
as my agent(attomey-in-fact)to act for mein any lawful way with respect to the following initialed subjects:
TO GRANT ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF (N) AND IGNORE THE
LINES IN FRONT OF THE OTHER POWERS.
TO GRANT ONE OR MORE, BUT FEWER THAN ALL, OF THE FOLLOWING POWERS, INITIAL THE LINE IN
FRONT OF EACH POWER YOU ARE GRANTING.
TO WITHHOLD A POWER, DO NOT INITIAL THE LINE IN FRONT OF IT. YOU MAY, BUT NEED NOT, CROSS
OUT EACH POWER WITHHELD. / Ate
INITIAL INITIAL
— (A) Real property transactions. _ Claims and litigation. /�
(B) Tangible personal property transactions. _ (J) ersonal and family maintenance.
(C) Stock and bond transactions. _ Benefits from social security, medicare, Q
(D) Commodity and option transactions. medicaid, or other governmental programs,
_ (E) Banking and other financial institution transactions. or civil or military service. J`D
(F) Business operating transactions. _ (L) Retirement plan transactions. t
— (G) Insurance and annuity transactions. _ (M) Tax matters /
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YOU NEED NOT INITIAL ANY LINES IF YOU INITIAL LINE (N). °° /
3
SPECIAL INSTRUCTIONS:
ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL INSTRUCTIONS LIMITING OR EXTENDING fHE
POWERS GRANTED TO YOUR AGENT.
UNLESS YOU DIRECT OTHERWISE ABOVE, THIS POWER OF ATTORNEY IS EFFECTIVE
IMMEDIATELY AND WILL CONTINUE UNTIL IT IS REVOKED.
This power of attorney will continue to be effective even though 1 become incapacitated.
STRIKE THE PRECEDING SENTENCE IF YOU DO NOT WANT THIS POWER OF ATTORNEY TO
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EXERCISE COF POWER OF ATTORNEY WHERE MORE THAN ONE AGENT DESIGNATED
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reliance on this power of attorney.
Signed this day of l\ 20ia —
R. J.ALTHOFF
Commission# 1367709
Your Social Security Number / Z ro Notary Public -California
z
Riverside County n
My Comm. Expires Nov 6,2013
State of Calif rnia
County of
On 2- before me, (here insert name and title of the officer), personally appeared
ho proved to me on the basis of satisfactory evidence to be the person(s) whose
name(s) is/are subscri ed to the within instrument and acknowledged to me that he/she/they executed the
same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
Signature Z • j I (Seal)
DOCL ENT PROMIDEDBBY STMW T�TITLE OF CFWFORNIH,INC. PmMnyGenenlDOC
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CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
State of California
County of I VG�2
On (JL � 1 before me, 4L/a-/A/
Daro Hero Irserl Ngme eac TIOe of the Officer '
personally appeared D LG
N8111BI6I0f s�rt61
who proved to me on the basis of satisfactory evidence to
be the persor rwhose nam�e(aj�ere subscribed to the
--w9 rr—instrument—and acwedge-to me that"
executed the s e it l�, erA#+eir authorized
capac t aie<and that hi signatu N*1n the
instrument the persq ( , or the entity upon behalf of
which the persoWacted, executed the instrument.
ELAINE RUBIN I certify under PENALTY OF PERJURY under the laws
Commission a 1914008 E of the State of California that the foregoing pare
z ; ,'a Notary Public -California z 9mPh I5
Riverside County ' true and correct.
My Comm.Expires Dec 18,2014
WITNESS my hand and official seal.. /f
PhM Norory sml Abm Signature
Sbaeuoe a ruwmy Ptbse
OPTIONAL
Though the informa Ion below is not required by law,d may prove valL to persons relying on the document
and could prevent fraudulent remora/and reattachment of ihis brm to another document
Description of Attached Document
Title or Type of Document
Document Date: Number of Pages:.
Signer(s)Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name: Signers Name:
❑ Individual ❑ individual
❑ Corporate Officer—Title(s): ❑Corporate Officer—Ttle(s):
❑ Partner—❑Limited ❑General ❑ Partner—❑Limited ❑General
❑ Attorney in Fact e ❑Attomeyin Fact
❑ Trustee rop of rhu nb here
❑Trustee Top d nwreb hare
❑ Guardian or Conservator ❑Guardian or Conservator
❑ Other: ❑Other:
Signer Is Representing: Signer Is Representing;
02007 Nabwd Notary Aemdefion-am De Sob Awe,P.Q eox 24021ChaLmoril,CA 91313-2402,m .
I'teaonaaJoWjyory ne"Beo7 RBWd8rCeBTbI6Rft140o875. W
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
State of California / 1
County of R / Y�i�aS✓(D� / Ji p
On ./2L y �� �/aZbefore me, 4L"1'/i✓4 let��/I�, A10%/7/�'� %4,WYG
—1 Here Invert Na and TNe of ate OIDcer
personally appeared HIAS 1LG L✓210K_a/-
Name(s)or Signers)
who proved to me on the basis of satisfactory evidence to
be the perswhose ram=(a)(9lrM subscribed to the
wI m Instrument and acknowledged to the that
executed the same ink eWW,-w authorized
capacity,(les(, and that lo by 1 erltherr signatul�SWon the
instrument the persnr)( , or the entity upon behalf of
• which the persoWacted, executed the instrument.
ELAINE RUBIN I certify under PENALTY OF PERJURY under the laws
E. Commission # 1914008 Z of the State of California that the foregoing paragraph is
< -® Notary Public -California z
z s true and correct.
z Riverside County
My Comm.Expires Dec 18,2014
WITNESS my hand and official seal.
Pence Notary Seal Above Signature.
SKyK of Ngtay Ftie
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent removal and reattachment of this form to another documenL
Description of Attached Document
Title or Type of Document:
Document Date: Number of Pages:.
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name: Signer's Name:
❑ Individual ❑ Individual
❑ Corporate Officer—Title(s): p Corporate Officer—Title(s):
❑ Partner—❑ Limited ❑General _ _ ❑Partner—❑ Limited ❑General
❑ Attorney in Fact ❑Attorney in Fact
❑ Trustee Top of thumb here ❑Trustee Top!>hemb here
❑ Guardian or Conservator ❑Guardian or Conservator
❑ Other: ❑Other:
Signer Is Representing: Signer Is Representing:
®200r National Notary Assade6on•9=De Soto Ave,P.O.BM 2402.Ohatmvorlh,CA 91313-2402•w .NAo rielMvbryorg Item 9590T Reorder.CallT0Il-Free14Dpa7aE627
To Who It May Concern
In the morning of June,1,2012 I spotted my neighbor Thomas Allen Worthy walking faintly toward
the back of his car when he suddenly collapsed on the curb. I was very concerned and called 911.
As the ambulance was taking Allen a man in a truck came and entered Allen's apartment and then
came out and drove off in the Black Mercedes E500 in question and then I never saw it again.
Sincer
Traci Diaz
3737 east calle de carlos apt#1
palm springs ca. 92262
Mercury Insurance Company
Please be advised that Thomas Allen Worthy is a close, long time friend of mine. He was
hospitalized in late May thru June and was placed in a medically induced coma for nearly
2 weeks. During that time I visited Mr. Worthy's bedside several times, and at no time
did Mr. Worthy ever speak. I was shocked and dismayed at his condition. We believed
that he had suffered a stroke, but brain scans did not reveal that.
Please assist Mr. Worthy with his medical policy as I know he is out of pocket for
numerous expenses, including dental work.
Mo,sL$mcerely Yours,
i
hilip Ward
October 15, 2012
To whom it may concern,
I am a longtime friend of Mr.Thomas Allen Worthy. On May 21, 2012, Mr. Worthy was
involved in an automobile accident. It was immediately after this event that I noticed
dramatic and shocking changes in his health-most notably, his mental state. I visited him on
several occasions at Eisenhower Hospital in Rancho Mirage, California, where he had been in
what I believe was a comatose state of some degree. I and my mother, Janet Robinson later
visited him after he had been placed into a nursing facility in Palm Springs.
During this time and even after he had returned home, his condition was quite alarming. I
observed a once thriving and healthy active man as now frail, weak, unable to walk steady,
and most notably, a very high level of mental confusion, memory loss and the inability to
properly care for himself.
While I have seen improvements in Mr. Worthy, I am still alarmed deem to
me, and my family as anywhere close to being recovered from hi .
Mo Sincer y Yours,
Matthew
65 Golden State Street
Rancho Miraee. Ca. 92270
STATE OF CALIFORNIA
OEPARTWNT OF CALIFORNIA HIGHWAY PATROL
VEHICLE
E REPORT ,^ t NOTE: C P Y T IS FURNISHED TO A PEACE
Y L h'LT y r OFFICERS 1 THE FCALIFORNIAURNISHED O AY PATROL
CHIP 180(%V.6-10)OR 061
REPORTING DEPARTMENT LOCATION CODE DATE/TIME OF REPORT NOTICE OF STORED VEHICLE FILE NO. .+s T
DELIVERED PERSONALLY ❑ ;'/�! ,�..�/-. �' /
LOCATION TOWED/STOLEN FROM ODOMETER READING VIN CLEAR IN SVS? ^llHS ❑NO DATE I TIME DISPATCH NOTIFIED LOG NO.
LIG CLEAR IN SVS4 ❑ -r
ES NO
YEAR MAKE .^ MODEL r...c— BODY TYPE COLOR LICENSE N0. ❑ONE MONTH/YEAR_ STATE
✓er .--; .-.- .. .ems✓ �d/\ Imo/ f ^',.a.?'�. .L.''
VEHICLE IDENTIFICATION N 7 r. > �� O ENGINE N0. VALUATION BY ❑OFFICER
� _ { ❑0-300 ❑ 301-0000❑4001+
F ' �STERED OWNER �❑SAME AS R/ ,_� LEGAL OWNER
- 1•/fir
lJ --
❑ STORED. ❑ IMPOUNDED ❑ RELEASED ❑ RECOVERED-VEHICLE/COMPONENT
TOWING/STORAGE CONCERN (NAME.ADDRESS.PHONE) STORAGE AUTHORITY I REASON
TOWED TO/STORED AT AIRBAG? DRIVEABLE? VIN SWITCHED?
❑YES ❑ NO ❑ 1 ❑2 ❑YES n NO ❑JUNK ❑UNK ❑YES ❑ NO
CONDITION YES NO ITEMS YES NO ITEMS YES NO ITEMS YES NO TIRES/WHEELS CONDITION
NRECKED SEAT(FRONT) REGISTRATION CAMPER LEFT FRONT
BtiRNED HUUK per 431 P)CVC SEAT(REAR) ALT./GENERATOR VESSEL AS LOAD RIGHT FRONT
VAN ALIZED RADIO BATTERY FIREARMS LEFT REAR
ENGy j TRANS.STRIP TAPE DECK DIFFERENTIAL I JOTHER RIGHT REAR
MTSA PARTS STRIP ITAPES TRANSMISSION (SPARE
DODS'METAL STRIP OTHER RADIO AUTOMATIC HUBCAPS
SURGICAL STRIP per 431(b)GVC IGNITION KEY MANUAL SPECIAL WHEELS
RELEASE VEHICLE TO: ❑R/OORAGENT GIAGENCVHOLD ❑22850S CVC GARAGE PRINCIPAL AGENT STORING VEHICLE(SIGNATURE) DATE TIME
NAME OF PERSON I AGENCY AUTHORIZING RELEASE LD.NO. i DATE CERTIFICATION. I,THE UNDERSIGNED,DO HEREBY CERTIFY THAT I AM LEGALLY
�II AUTHORIZED AND ENTITLED TO TAKE POSSESSION OF THE ABOVE DESCRIBED VEHICLE.
SIGNATURE OF PERSON AUTHORIZING RELEASE SIGNATURE OF PERSON TAKING POSSESSION
--- STOLEN VEHICLE/COMPONENT ❑ EMBEZZLED VEHICLE ❑ PLATE(S)REPORT
DATE I TIME OF OCCURRENCE ��� DATE/TIME REPORTED �f NAME jOF REPORTING PARTY(RIP) ER LICENSE NO./STATE
d
LAST DRIVER OFVEHICLE DATE/TIME �J ADD
RESS OF R/P TELEPHONE OF R/P
7
I CERTIFY OR DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF L^i� ,jNNATURE OF PE?N A .KING REPORT ,--.
THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
REMARKS "-- -
(LIST PROPERTY,TOOLS,VEHICLE DAMAGE,ARRESTS]
DRIVER'S NAME AR RESTED(SECTION? REPORTED BY CARGO/TYPE? VALUE$
❑YES ❑NO ;❑YES 0 L OF LANDING ATTACHED
b '
FRONT •` e ® LEFT SIDE ® ®y RIGHT SIDE REARTOP
SIGNATURE OF OFFICER TAKING REPORT I.D.NO, SUPERVISOR REQUIRED NOTICES SENT TO REGISTERED ❑YES 'DATE NOTIFIED
AND LEGAL OWNERS PER 22852 CVC? NO
OSP 10 118905
Chp1
VANCOUVER ISLAND
healauthority
November 21, 2012
Attention: To Whom It May Concern
Regarding: Thomas Allen Worthy
I am writing this letter to provide documentation that Mr.Thomas Worthy was admitted to the Royal
Jubilee Hospital in Victoria, British Columbia, Canada between November 4-22, 2012 due to medical
reasons. Since this admission was unexpected, I know that there are many personal matters that he was
unable to attend to due to his hospitalization. Please accept this letter as support around his inability to
attend to responsibilities or commitments that he might have made prior to his admission.
If you require further information, I can be reached (250) 213-8306.
Sincerely tu P1
Sarah Oliver MSW, RSW
Social Worker
One North and One South
Royal Jubilee Hospital
Cell 250-213-8306
a .,. lhziAL
4,
LIM
Our Vision: Healthy People, Healthy Island Communities, Seamless Service
ALAL
VANCOUVLH ISLAND
health Worthy,Thomas Allen (Allen)
a ul thority Med Rec#: 8523250/Encntr#: 92009755087
Royal Jubilee. Acute Care
23—OCT-1961 51 Years Male Inpatient Acute
RECORD OF ADMISSION—SEPARATION Physician/Family;
Most Responsible Physician: t0000998890]House Physician,RJH
ow
�
Privacy Status:
Pre—Reg Date: \Reg.Date: O4—N0V-2012 23:55 J Accom: Emergency—RJH,yt'/ b1A�L 4
Visit Reason: E epbalopathy ---'�'�
Referring Facility Admit Source: Emergency Dept Admit Type: Emergency
Pastoral Care Visit? Religion: E.L.O.S: 0 days
Permanent Address: Temporary Address:
1760 Richmond Ave 301-919 Douglas St _� 8
Strathcona Hotel
Victoria British Columbia Canada V9V 9V9 ictoria Brrttsh Columbia Canada
Home: (760)537-7003 Cell: Phone: ..0:7-70o
3
W k_�Emergency Contact. Sister Contact1: riend
W.hinen,..Sandry Ward,Phi��
Lrk :::
Cell: Home: Cel• (813)334-5034
Work:
Citizenship: Other Arrival Date: 29—OCT-2012 BC Resident: No
Provincial Health Number: 9754-585-161
Insurer: BC Health Insurance Plan
Accident Type: None ( �APPLICATION FOR BENEFITS/RELEASE OF INFORMATION/RESPONSIBILITY FOR VALUABLES.
By my signature below,
1) I hereby make application for benefits under the BC Hospital Insurance Act and ertify t this appl' n is true a cc ect;
2) I acknowledge and agree that information collected as part of the Admission Pro ss y e used o cond ict patient atisfa�tion
and outcome surveys by the Vancouver Island Health Authority(VIHA)to impr se v ces of ed;and
3) 1 acknowledge that I am responsible fo my pe nal b Ion�giinngs�a �d/or prope t t I ave not placed i a e pin
Signature of W' ess(Hosp.Employee) Date. Signature of Ap ican
It is again 'g,law to make a false statement on an application. (Patient or Legal Representative)
Print Date/Time: 05—NOV-201200:43
Patient Name: Worthy, Thomas Allen
i 8523250 92009714519:21 it
VAN C6UVER ISLAND MRN: 23-OCT-1961 Qfi) 511'earG •k� it
health-authority� ------
Cate of&rth: 6052 FairLwaV Circle E _
Palm Springs 92 264
NON-RESIDENT OF CANADA AGREEMENT 760-537-7003
o2-NOV-2012 U 13
1. GOVERNING LAW AND JIURISDICTION AGREEMENT
1.1 I hereby agree that the relationship and the resolution of any and all disputes arising between myself and the doctor
(as well as his or her agents, delegates or employees), including any issues related to this Agreement, shall be
governed by and construed in accordance with the laws of the Province of British Columbia(BC) and the laws of
Canada applicable therein.
1.2 I hereby acknowledge that the treatment will be performed in the Province of BC and that the Courts of the
Province of BC shall have exclusive and preferential jurisdiction to entertain any complaint, demand, claim,
proceeding or cause of action,whatsoever arising out of the treatment. I hereby agree that if I commence any such
legal proceedings, I will do so only in the Province of BC, and hereby irrevocably submit to the exclusive and
preferential jurisdiction of the Courts of the Province of BC.
2. HOSPITAL CHARGES&FINANCIAL RESPONSIBILITY
• 1,, i I ,hereby assume responsibility for all costs incurred as a result of
anent or urnorize epresen alive
my hospital stay and/or outp rent service with the VIHA.
• I have received a listing of the current market rates for non-residents of Canada and have been notified that
Physician fees(Specialist/GP's)are NOT INCLUDED and will be invoiced separately by the Physician.
• I understand market rate for a non-resident of Canada Emergency visit and the Emergency Physician fee are
payable at the time of registration. The Emergency charge is non-refundable if I leave the department before
being seen by a Physician.
• •I authorize/request that my insurance company release payment directly to the VIHA.
• The VIRA has the right to release any information acquired in the course of my Medical and/or Surgical
treatment that may be needed to process my account for payment.
• Any outstanding debt may be registered with Canadian Immigration and could impact any future access to
Canada.
• If the account is not satisfied in total or in a reasonable amount of time, I remain fully responsible for the
outstanding and any accrued interest ch es.
IJr e egad and ack a yledg I_ onsibi hies witjT Tespeci to i ss#1 and#2 above.
r,-�-
anent or Autho epi•esentative)Signature !� Witness' Patient(or Autho zed Representative)Name(please print) Witness Name(please print
Qc� i�CV 1� � � ��
Date �
CREDIT CARD AUTHORIZATION
The cardholder gives the VDIA authorization to process through VISA or MasterCard any diagnostic charges,medical supplies
and in-patient costs incurred as a result of the patient visit not paid for in advance.
Name of Cardholder:
Please Print
MASTER
VISA CARD PLEASE SUPPLY CRAAGE CARD NUMBER AND SIGN
® � �PIAI I I DATE
AI
AUTHORIZED SIGNATURE
fib-05-40093.0 Version 2 RJH&VGH ONLY Distribution:patient(yellow copy),Finance(white copy)
RIMion Services
1952 Bay Street Vi s Y ;Y�, p' °J138