All of the following information must be provided in order to receive assistance

All of the following information must be provided in order to receive assistance

In agreement of this statement please provide your full name below, along with the date of signature.

I give Be An Angel Fund, Inc. the right to interview and/or take photographs, audio or visual-recordings of me/my child to be sued in promotional, education, or fundraising materials including, but not limited to videotapes, pamphlets, and brochures. I understand my/my child's name may be used in connection with these materials. By signing this media release, I intend to legally bind myself, my minor children, my heirs, executors, and administrators. I acknowledge that Be An Angel Fund, Inc. shall have all rights of copyright in and to such photographs and videotapes and may use such copyright fully. I also hereby release Be An Angel FUnd, Inc. and its officers, agents, and employees from all liability connected with the taking and use of these materials as is authorized by Be An Angel Fund, Inc. In addition, I waive all rights, interest, or claims from payment in connection with any exhibition or release of these materials. This consent is voluntary, and I give it in the interest of public information, education, and the furtherance of the goals of Be An Angel Fund, Inc. or other lawful purposes.

Refusal to provide necessary documentation or to answer an interviewer’s questions will disqualify me and my household from assistance. Any false or misleading information provided in writing or verbally will disqualify me and my household from assistance. I certify that all information provided to Be An Angel either in writing or verbally is correct and true to the best of my knowledge. Additionally; I give permission for Be An Angel staff to verify information by contacting any party I have listed or verbally mentioned in the process of seeking assistance. Any discrepancies between my application information and verification efforts will be provided to me for clarification. I release Be AN Angel from any liability or legal responsibility that may arise from the verification process.

Clients have a right to all of the services of the agency they qualify for (as long as they follow the guidelines). The services will be provided in the most efficient manner that meets the client’s needs. Each client has the following basic rights: 1. A right to respect, consideration, and safety 2. A right to make his/her own life decisions 3. A right to privacy and confidentiality in personal matters 4. A right to discontinue services with Be An Angel at any time 5. A right to any information kept by Be An Angel about him/her, and may review personal records upon request, by established procedures. Each client may record entries in his/her file. Each client has the following rights in regard to services available: 1. A right to have services available posted for easy access to view them, and to a copy of the description of services. 2. A right at the time of intake to have guidelines explained and to sign understanding and consent to follow these guidelines, and to a copy of the guidelines. 3. A right to be informed of Client Grievance Resolution Procedures and to a copy of these procedures.

Any client who has a complaint, problem, question, or grievance should immediately bring it to the attention of the program director The parties are encouraged to resolve the problem in the most direct fashion, at the most immediate level, and in the least complicated manner. However, if a satisfactory resolution is not received at that level, the client should then promptly take the matter to the next level as follows: 1. Executive Director 2. Be An Angel Board Grievance Committee If the matter is not resolved at the Executive Director’s level, the client should present his/her problem, grievance or complaint, in writing, to the Board Grievance Committee, 2003 Aldine Bender, Houston, Texas 77032. The Committee will investigate the complaint and recommend possible solutions. There is no standing meeting time; the Committee meets on an as-needed basis. A written decision by the Committee may be expected not more than fourteen (14) days from receipt of the written complaint unless otherwise notified in writing by the Committee. The client must include a current mailing address and phone number on all correspondence. No decisions will be made or reported via telephone. The decision of the Board Grievance Committee shall be final.

Whereby I agree, that should I receive goods and/or services from Be An Angel Fund, Inc. (BAA) as a result of this assistance request, I do so entirely of my own initiative, risk and responsibility. Therefore, in consideration of BAA approving my request and providing requested goods and/or services I do hereby, for myself, all those on behalf of whom I may have made the request, my or their heirs, executors and assigns, release and forever discharge BAA and any of tis affiliates, or subsidiaries and all of its officers, agents and employees, acting officially or otherwise, and any school district from any and all claims, demands, actions or causes of action on account of my death, or any injury to me or to those on behalf of whom I may have made the request, or my personal property, which may occur from any cause, including negligence of any type. Therefore, netierh BAA nor its affiliates or subordinates, officers, agents, and employees, nor any school district shall be or become liable or responsible for any loss, injury, or damage to any person, property, or otherwise in connection with any good and/or service resulting directly or indirectly from any defect in or misapplication of said goods and/or service including any breakdown in machinery or equipment, or for any loss or damage resulting from defective equipment, materials, nutritional products, and that netiehr BAA nor any of its affiliates or subsidiaries, officers, agents and employees, nor any school district shall be or become liable or responsible for any additional expenses or liability sustained or incurred by recipient of goods and/or services as a result of any of the foregoing causes. Additionally, I acknowledge that the welfare and safety of any and all of my minor children who might be the beneficiaries of goods and/or services provided by BAA will be my sole responsibility and add my consent on their behalf that all stipulations and contingencies as stated above are applicable to them as well.