I certify that the information provided is true and correct as of the
date opposite my signature below. Any intentional misrepresentation of
the information contained in this Application will result in the loss of
current and future assistance from the Endowment Fund and may result in
civil and/or criminal liability.
The Applicant hereby releases the Endowment Fund from any and all liability,
which may arise from the sharing of this information with third parties.
The Applicant hereby grants permission to the Endowment Fund to publish
in print and/or electronic format, the likeness or image of myself, child
and other family members. The Applicant releases all claims against the
Endowment Fund with respect to copyright ownership and publication including
any claim for compensation related to the use of the materials.
For the purpose of procuring assistance from the Endowment Fund from time
to time, the Applicant will furnish the foregoing information as a true
and accurate statement of his/her circumstances, including health, finances
and any other information contained in this Application. Authorization
is hereby given to the Endowment Fund to verify in any manner it deems
appropriate any and all items indicated on this statement. The undersigned
also agrees to notify the Endowment Fund immediately in writing of any
significant change in any of the foregoing information.