Nonviolent Crisis Intervention Waiver –   2024
Participants who attend Active Lives Canada (hereinafter referred to as Active Lives) sometimes
demonstrate difficult and challenging behaviour which at times can take the form of a physically acting
out episode (disruptive and/or assaultive behaviour). To respond to this, support workers and Senior
Staff at Active Lives are trained and certified in Crisis Prevention Institute's (CPI) Nonviolent Crisis
Intervention techniques.
Nonviolent Crisis Intervention techniques are safe, non-harmful control and restraint techniques to
keep an individual safe until he/she can regain control of his/her challenging behaviour. Nonviolent
Crisis Intervention is used only as a last resort when a person is a danger to self, others and/or property.
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Email *
Name of Participant *
In the event that the above named participant loses control resulting in a physically acting out
episode, becoming a danger to self, other and/or property, we/I hereby consent that support workers
and/or Senior Staff of Active Lives implement the techniques of Nonviolent Crisis Intervention.(Name of Parent/Guardian)
 *
In consideration of Active Lives making this service available to the above named participant, we/I
hereby release and forever discharge Active Lives, its staff, contracted individuals as well as
employees, officers, directors and contracted individuals of Active Lives from any and all actions,
causes of actions, claims and demands for damages, loss or injury howsoever arising, which have been
or may be sustained by the above named participant in consequence of Nonviolent Crisis Intervention. (Name of Parent/Guardian)
 *
It is understood and agreed that this agreement shall be binding upon us/myself, my heirs, executors
or administrators as the case may be.
Dated at , Ontario this day of , 2023
Print: Signature:

Legal Parent/Guardian Legal Parent/Guardian
Active Lives hereby accepts the foregoing Contract this day of , 2023
Per:

Authorized Representative for Active Lives
 *
A copy of your responses will be emailed to the address you provided.
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