Child/dependent with life-threatening medical condition:

If there is more than one, fill this out for the dependent with the most severe condition

Certification By Applicant:

I hereby authorize Angels' Place. (hereinafter “AP”) and its representatives, agents, employees or designees to contact me for the purpose of requesting any and all information concerning any pertinent information which they may have concerning my application. I also authorize AP and its employees, agents, representatives, and designees to investigate all statements contained in this application for decision.

I understand that the submission of this application for help to AP does not create a promise of help or the creation of a contract for help.

I certify that all information stated in this application is true and complete. I have read and understand the foregoing statement contained in this section entitled “Certification by Applicant.”

Certification by Applicant *