Agreement
By submitting your application (the “Application”) for the ALGS Assistance Program (the “Program”), which includes Financial Assistance, Assurance Support, Essential Mental Health, and Continuity of Care, you hereby agree to these Terms and Conditions, which shall become a binding agreement (the “Agreement”) between you and the Alagille Syndrome Alliance (“ALGSA”) as of the date that your application is submitted.
Requirements
The guidelines set forth on the Program flyer and on this link are incorporated into and made a part of this Agreement. You must be 18 years or older to apply for the Program, and you must be currently receiving treatment for Alagille Syndrome, or the parent or legal guardian of a child currently receiving treatment for Alagille Syndrome (an “Applicant”). An Applicant may apply for the Program as needed during the year, but an Applicant or an Applicant’s Immediate Family (as defined herein) will only be awarded Funds under the Program once in a 12-month period. As used in this Agreement, the “Immediate Family” includes the Applicant’s caregivers, spouse, parents, children, and shall apply regardless of whether such relations occur through adoption, half relations, or step relations. You must certify your diagnosis in the Application, or if you are submitting an application on behalf of an Applicant, you must certify the Minor Applicant’s diagnosis of Alagille Syndrome in the Application. You may use a public social media page or other medical support website to confirm the diagnosis, or you may request that your health care provider sends confirmation of the diagnosis directly to ALGSA using a medical eligibility form provided by ALGSA (please request this form by emailing alagille@alagille.org). The original invoice for which funding is sought must be attached to the Application. Funds shall be disbursed directly to the third-party payee, if such payee is located in the United States and has issued the invoice submitted with the application (the “Payee”). If you are requesting continuation of care materials as outlined in this program, please submit a photo or screenshot of the requested materials along with costs.
Limitation of Program
You understand and agree that the date and timeframe in which any funds disbursed in connection with the Program (the “Funds”) cannot be amended or changed to fulfill a time-sensitive or overdue invoice. Receipt of the Funds should not be relied upon for emergency or exigent circumstances. ALGSA expressly disclaims any liability, damages, claims, or penalties, including late fees or damages due to a cessation of services, caused by a failure of the Funds to reach Payee within a specific timeframe or by a specific date, due to a partial payment on amounts due and owing, or for any other reason, including a delay in processing by the Payee. ALGSA further makes no guarantees with respect to the date on which the Funds shall be received by the Payee.
Discretion
ALGSA anticipates it shall make up to ten (1) $1000 awards; however, ALGSA expressly reserves the right to award Funds and administer the Program in its sole discretion. ALGSA may discontinue or suspend the Program at any time in its sole discretion and with no notice to you.
Warranty
You, on your behalf and on behalf of any Applicant, shall comply with all federal, state, and local laws, rules, regulations, and ordinances in connection with this Agreement, your Application, and any Funds. You further agree that the payment of Funds on your behalf or on behalf of any Applicant shall not violate any federal, state or local law, rule, regulation or ordinance, including, without limitation, laws governing the use and exchange of protected health information, privacy rules and regulations, taxation, and copyright and trademark rules and regulations. You understand and agree that ALGSA makes no warranties or representations with respect to any tax obligations incurred as a result of the Program or the Funds, and you expressly understand and agree that all withholdings, liabilities, and contributions shall be solely your responsibility or the responsibility of the Applicant. If submitting this Agreement on behalf of an Eligible Participant other than yourself, you expressly warrant and agree that you have authority and permission to submit such application and that all information contained in the Application is truthful, accurate, and complete.
Grant of Funds
You affirm you have no business that would conflict in any manner or degree with the Program or the mission and purpose of ALGSA. ALGSA expressly reserves its right to terminate this Agreement immediately and upon notification that you have engaged in conduct that is deemed to reasonably conflict with the mission and purpose of ALGSA, as solely determined by ALGSA, and no Funds shall be paid on your behalf. ALGSA reserves the right to request removal of any public statements, including those on social media, in its sole discretion (“Public Statements”). You shall not post any Public Statements that tarnish the reputation or goodwill of ALGSA. Among any other remedies available to it, ALGSA expressly reserves its right to terminate this Agreement immediately upon notification that any Public Statements have been distributed in violation of this provision, and obtain an injunction to enjoin any further dissemination of Public Statements in violation of this provision, in addition to any other remedies available to ALGSA. If executing this Agreement on behalf of an Applicant, you hereby give your authority and permission for ALGSA to verify the relationship between you and any Applicant. You further give ALGSA authority and permission to contact any third party, including the Payee, to confirm the veracity of any materials submitted in connection with the Application or the Program. Submitting an application does not guarantee approval of any assistance.
Indemnification
You, on your behalf, and on behalf of any Applicants, your spouse, heirs, next of kin, assigns, executors, administrators, agents, successors, legal representatives, or any others who may claim on your behalf (collectively the “Indemnifying Parties”) agree to indemnify, defend, and hold harmless ALGSA and its affiliates from and against any demands, actions, suits, damages, settlements, costs, liabilities, losses, claim, and expenses, including reasonable attorneys’ fees and costs, as a result of: the Indemnifying Parties’ negligence or willful misconduct; the inaccuracy or breach of any of the covenants, representations, and warranties of this Agreement; arising out of or related to the issuance of Funds under this Agreement, including to any Payee; any tax liability, contributions, or any other payment or fee assessed in connection with any tax liability associated with the Program and the Funds, including penalties and interest if applicable; and/or any other violation of any federal, state, or local law, rule, regulation or ordinance, including without limitation rules and regulations associated with claims of defamation, or copyright or trademark rules or regulations. This provision shall survive the termination of this Agreement.
Termination
ALGSA may terminate this Agreement at any time with five (5) days prior written notice to you.
Release and Waiver
By submitting the Application and entering into the Agreement, you, on your behalf, and on behalf of any Applicants, your spouse, heirs, next of kin, assigns, executors, administrators, agents, successors, legal representatives, or any others who may claim on your behalf (collectively the “Releasing Parties”), hereby forever waive and release ALGSA, and its owners, employees, trustees, contractors, volunteers, representatives, agents, assigns, successors, and anyone else acting for or on its behalf (collectively referred to herein as “ALGSA”) from any and all liability present, past and in the future relating to, connected with, or arising out of the Program, the disbursement of any Funds, and this Agreement. The Releasing Parties promise not to sue, and hereby forever irrevocably waive, release, remise, and discharge ALGSA from any and all liability, claims, demands, actions or rights of action, or damages of any kind, related to, arising from, or in any way connected with the Program, any Funds, and this Agreement. This Release and Waiver applies to all claims, demands, damages, costs, expenses, actions and causes of action foreseen or unforeseen, including but not limited to negligence, breach of statutory or other duty of care. The Releasing Parties understand and agree that this Agreement and Waiver and Release is intended to be as broad and inclusive as permitted by law.
Permission to Use Likeness/Name
You, on your behalf and on behalf of any Applicant (collectively for this paragraph “You”), expressly grant ALGSA the ability to use your name, appearance, image, likeness, voice, identity, picture or personal story, or the name, appearance, image, likeness, voice, identity, picture, or personal story of any Applicant (together the “Likeness”) in any manner in connection with ALGSA’s business (including without limitation for purposes of advertising and trade). You release Your rights of publicity, editorial rights, or other rights with respect to Likeness in connection with ALGSA’s business and acknowledge that You will not receive any compensation for ALGSA’s use of the Likeness.
Waiver of Breach
None of the terms of this Agreement shall be deemed to be waived or modified except by a written document executed by ALGSA and you. Failure or delay of either party hereto to enforce any of its rights under this Agreement shall not be deemed a modification or a continuing waiver by such party of any of its rights under this Agreement.
Entire Agreement and Severability
This Agreement constitutes the entire agreement between you and ALGSA. In the event that any provision of this Agreement is found to be invalid, unlawful, or unenforceable, the remaining provisions shall remain in full force and effect and shall not be affected by the invalid, unlawful, or unenforceable provision or by its severance from this Agreement.
Governing Law
This Agreement shall be governed by and construed in accordance with the laws of the State of Texas without regard to its choice of law principles. The exclusive venue for all disputes relating to, arising under, or connected with this Agreement shall be the courts located in Austin, Texas.
I am 18 years of age or older, and I expressly warrant and agree that all information contained in the Application, including any invoices or diagnosis confirmation, is truthful, accurate, and complete. I have read the Application and the Terms and Conditions in their entirety, including the release contained in the Terms and Conditions before signing below, and I fully understand the contents, meaning and impact of the Terms and Conditions. I have not obtained payment from any other source for the invoice(s) submitted. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.
