IN ORDER FOR DREW'S PUZZLE PIECE INC, A 501(c)(3) NON-PROFIT ORGANIZATION, TO ADVANCE SUPPLEMENTAL FAMILY SUPPORT EXPENSES IN CONJUNCTION WITH THE MEDICAL TREATMENT OF THE CHILD (REFERENCED IN SECTION 1 OF THIS FORM), I DO HEREBY AFFIRM AS FOLLOWS:
- The undersigned are the parent(s) or guardian(s) of the child.
- The undersigned further agree(s) to return any unused funds immediately to Drew's Puzzle Piece Inc so that those funds can be utilized by the organization to benefit other families.
- The undersigned acknowledge(s) and agree(s) to maintain records that will be made available to Drew's Puzzle Piece Inc upon reasonable request, detailing the expenditures made from the funds provided by the organization.
I have read the guidelines for financial assistance and I declare that the information furnished on this application form, including attached or mailed sheets, is true and correct to the best of my knowledge. (Please refer to the checklist at the top of page one of the application and attach all required documentation prior to submitting the application.)
When awarding a grant, Drew's Puzzle Piece Inc is not advocating for the specific health care providers or equipment suppliers, but only providing the funds to enable you to access the services and equipment. You acknowledge and agree that accepting a grant from Drew's Puzzle Inc is strictly voluntary. Furthermore, you agree that you will be responsible for any choices you make regarding the medical care, equipment or supplies, or for the failure, malfunction, repairs, or ongoing maintenance of any equipment obtained as a result of the grant of funds.