GRANT APPLICATION #2

By signing below, I/we, First Name*   Last Name* and   First Name*   Last Name*(enter n/a if not applicable), of the city/town of   City/Town*in the province of   Province*   , hereby acknowledge and agree to the following:

1. I/we have complied with all of the application conditions and without limiting the generality of the foregoing, I/we hereby confirm that the primary applicant is of the age of majority in the province or territory where the primary applicant lives. 
2. I/we declare that all of the information provided in this application is, to the best of my/our knowledge and belief, true, accurate, and correct.
3. I/we understand that any falsification or willful omission of fact made in this application or in connection with any background investigation may be sufficient grounds for rejection of this application, or, if discovered after a grant of financial assistance has been allocated or awarded, for immediate termination of financial assistance or immediate rescinding or repayment of any portion of any grant of financial assistance, with costs. I/we further understand that any failure or refusal by me/us to comply with the terms of this Release shall result in my/our disqualification from consideration for financial assistance.
4. I/we consent to the collection, use, and retention of my/our personal information, including medical and financial information, by The Gift of Love & Hope Inc.
5. I/we give permission to The Gift of Love & Hope Inc. to collect and review my/our personal, medical, and financial information that is held by other organizations, healthcare providers, and financial institutions, including any credit bureaus. I/we further give permission to all holders of such personal, medical, and financial institutions to discuss with The Gift of Love & Hope Inc. my/our relevant personal, medical, and financial information, consent to the release of such information orally or in writing, and hereby release such holders of my/our personal, medical and financial information in perpetuity from any claims based upon statements they make to The Gift of Love & Hope Inc.
6. I/we give permission to any agent, attorney, or representative of The Gift of Love & Hope Inc. to receive a copy of any information obtained in the file of any federal, provincial, or local governmental agency concerning or relating to me/us. I/we further consent to the release of such information and waive any right under provincial or federal law concerning notification of the request for a release of such information. 
7. I/we understand that any grant funds I/we receive (i) will be paid directly to the primary applicant’s fertility clinic; and (ii) must be used within twelve months of the date of notification to the applicant(s) that such grant funds will be provided (special circumstances may be reviewed by the Board for consideration). 
8. I/we agree to indemnify, defend, and hold harmless The Gift of Love & Hope Inc., their respective employees, directors, volunteers, contractors, associates, and any other related parties, and their respective heirs, executors, administrators, successors and assigns from any and all claims, causes of action, demands, loss, injury and liability whatsoever which may arise or occur in connection with or as a result of this application, the processing and review of this application, or my/our participation in the financial assistance program. 
9. I/we understand and agree that this Release will be governed by the laws of the Province in which the applicant resides and the applicable laws of Canada.
10. The conditions and the terms of this Release shall apply to and be binding on my/our heirs, executors, successors, and assigns. 

Dated this   Day*  day of   Month*   , 20   Year*   .

First Name*   Last Name*  
 Signature*   

First Name*   Last Name*   (type n/a if not applicable)
Signature*  (sign n/a if not applicable)