Family Donation Request

Thank you for your interest in The TPDS Inc Donation Program. Please complete this registration request in its entirety. All parts of this form and requested documentation need to be completed and submitted for consideration. We are committed to making our community a better place and although we'd like to grant every request, our supply is limited through different times of the year. Request will processed on a fist come first serve basis. Donations are limited to Orange, Seminole, Osceola, Lake and Polk County FL Residents. *

Date

Time

HOUSEHOLD INFORMATION

Head of Household/Applicant (HH) *

First

Last

Name of 2nd HH (Adult in the home if applicable)

First

Last

The best contact number to reach you

Email

Confirm Email

Please enter your email, so we can follow up with you.

Residental Address *

Address Line 1

City

State

Zip Code

Enter Child's Full Name | Age | Date of Birth (If no children enter N/A) *

First

Middle

Last

First

Middle

Last

First

Middle

Last

First

Middle

Last

Select the type of donation the family's in need of: *

Please Note: all items requested may not be available.

INCOME AND DOCUMENTATION

Household Annual Income *

I have reliable Transportation *

Yes
No

Please describe your need for this donation *

Upload Current Picture ID and/or Utility Bill of HH/Applicant *

Click or drag files to this area to upload. You can upload up to 3 files.

Examples: Head of Household/Applicants valid gov issued photo ID - FL driver's license - State of FL photo ID - Passport - Electric bill - Water bill - Gas bill. Donations are limited to Orange, Seminole, Osceola, Lake and Polk County FL Residents.

ATTESTATION | PHOTO CONSENT RELEASE

Yes, I understand and agree
No, I do not understand nor agree

I hereby authorize TPDS Inc. and those acting in pursuant to its authority to: (a) Record this organization/program and participants likeness and voice on a video, audio, photographic, digital, and electronic or any other medium. (b) Use the organization/program name in connection with these recordings. (c) Use, reproduce, exhibit or distribute in any medium (e.g. print publications, video tapes, CD-ROM, Internet) these recordings for any purpose that TPDS Inc. and those acting pursuant to its authority, deem appropriate, including promotional or advertising efforts. I release TPDS Inc. and those acting pursuant to its authority from liability for any violation of any personal or proprietary right I or this program may have in connection with such use. I understand that all such recordings, in whatever medium, shall remain the property of TPDS Inc. I attest that the information proivde is accurate and true to the best of my ability. I have read and fully understand the terms of this release.

RELEASE | WAIVER | HOLD HARMLESS

Yes, I understand and agree
No, I do not agree

I understand that donations are not guaranteed and are 1st come 1st serve basis. We ATTEST that this organization/program would have no other way to provide these items for our participants. We further attest that all items donated will be used for the benefit of the program and participants we serve. We further attest that No items will be returned to the store or sold. Condition “As Is”, TPDS Inc. and its affiliates do not make any representations, warranties, or guarantees about the Donated goods or equipment, including any implied warranties of merchantability and/or fitness for any purpose. I am accepting the Donated goods and/or equipment “as is.” I understand that TPDS Inc. nor its affiliates will not provide any instructions or follow-up services, replacement parts, or repairs. Assumption of Risk. I understand that there are certain risks of injury that may arise from the possession, use or misuse of the Donated goods and/or equipment, including the risk of injury, disability, or death of my child or other persons, or damage to property. I assume full responsibility for all risks arising directly or indirectly from my possession, use or misuse of the Donated goods or equipment, both known and unknown, regardless of the cause. In consideration for receiving goods from TPDS Inc. and its affiliates, I hereby RELEASE, WAIVE, DISCHARGE, COVENANT NOT TO SUE AND HOLD HARMLESS: TPDS Inc. and its affiliates and any partner, employee, servant, representative, associate, officer, agent, volunteer and successor of TPDS Inc. (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, action, judgments, costs, expenses, court costs, attorney fees and causes of action whatsoever arising out of or related to use or misuse of the Donated Equipment, regardless of the cause and even if caused by negligence, whether passive or active, any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, WHETHER CAUSED BY THE, including but not limited to, SOLE, CONTRIBUTORY OR GROSS NEGLIGENCE OF THE RELEASEES, or otherwise, while participating in such activity, or while in, on or upon the premises where the activity is being conducted. Indemnity. I will defend, indemnify and hold TPDS Inc. and all Parties harmless from and against any and all liability, loss, damages, claims and attorney’s fees that may be suffered by any Party resulting directly or indirectly from the possession, use or misuse of the Donated goods by me or any other person, except and only to the extent the liability is caused by the gross negligence or willful misconduct of a Party. It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, personal representatives, executors and assigns, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Florida. I expressly agree that this Release and Hold Harmless Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of Florida, and if any portion of this Agreement is held to be invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute the Release For full, adequate, and complete consideration fully intending to be bound by same.

GDPR Agreement *