agree for Be Uplifted Inc. to hold any information collected in support of my application for assistance in regard to my Breast Cancer Diagnosis and subsequent treatment. I understand that my personal information will not be shared with any third party or others not associated with Be Uplifted Inc. Management Committee. I agree that if my application is successful and the assistance offered to me is of monetary value, I will keep the amount confidential between myself and Be Uplifted Inc.
I understand and am assured that my personal information will be kept in a secure location of which only members of the Management Committee have access to. I am aware that additional supporting documentation may be requested to assist in the processing of my application.
I acknowledge that Be Uplifted Inc. reserves the right to deny request for assistance if eligibility does not meet the required criteria.
I acknowledge that my file will remain open for a period of 12 months following initial referral date and that contact will occur on initial interview (phone and face to face), and on notification of outcome of the assessment of my case. I understand that should I require further assistance after my case is closed (12 months) a further application and a new assessment will be undertaken by Be Uplifted Inc. Management Committee.
I have read and understood this agreement and further agree that the information I have given is accurate and to the best of my knowledge. I give consent for Be Uplifted Inc. to procure the necessary information to complete my request for assistance.