The patient/child above, the undersigned do hereby affirm the following:
1. The undersigned are the parents or guardians of the child.
2. Financial assistance will be provided with the use of said funds to be specified by Isaac's Rays of Hope.
3. The undersigned further agree(s) to return any unused funds immediately to the Isaac's Rays of Hope so that those funds can be utilized by the organization to benefit other families.
4. The undersigned acknowledges(s) and agree(s) to maintain records that will be made available to the Isaac's Rays of Hope upon reasonable request, detailing the expenditures made from the funds provided by the organization.
Isaac's Rays of Hope will pursue restitution for grants if it is determined that the information submitted on the application is false. I have read the guidelines for financial assistance and the eligibility checklist and I declare that the information furnished on this application form, including attached sheets, is true and correct to the best of my knowledge.
Furthermore, the undersigned does hereby give continuing consent to Isaac's Rays of Hope to use images of any and all kinds of my child, myself, and our names, so long as they are only used on behalf of Isaac's Rays of Hope. I may void consent by selecting the void consent option and then filling in the signature section.