HFE Share It Forward, Inc. (“SIF”) Release and Agreement

With my signature I understand and agree that by filling out and submitting an application there is no guarantee of approval. I represent that all information provided in my application is true and correct and that the information that I have supplied may be verified with third parties including my employer. I understand that any false statement or omission of material facts may result in a rejection of my application. Under penalties of perjury, I certify that the facts and representations set forth in this application or in other documents I provide are true and correct. I consent to having a background or reference check by SIF or programming partners. I consent to the release of all information about me, whether personal, confidential, or otherwise, by my employer and other relevant entities or agencies only to SIF as necessary for SIF to verify the information I have provided is correct. I agree to the sharing of information requested on this application with SIF. Further, I understand that any decision by SIF or programming partners will be based on the facts presented on this application as well as the information gathered by SIF and programming partners, and comparison with other assistance requests/decisions, and the availability of funds; and I will hold SIF, the SIF staff, and the SIF Board of Directors harmless from any claims related to the payment or nonpayment of assistance by SIF or programming partners. I also consent to the sharing and disclosure of any pertinent medical information set forth on the application only to SIF or programming partners who have a need to know the information in connection with the consideration of my application.

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