I attest and agree to the following:

 (a) I am the parent/guardian of the patient and siblings listed on this application.

(b) If representing the family, a parent or guardian has given his or her consent to provide the information in this application, as well consent to the release of medical and contact information, and has agreed to sign any additional forms and consents related to this application.

(c) The information provided in this application is truthful and accurate. ALSF shall be immediately notified if any information in this application changes, including the family's address or patient's medical condition.

(d) ALSF will not be responsible or liable for any reason to the family or the representative, regardless of whether or not ALSF supports this applicant or any other applicant.

(e) I understand the program is limited by available resources and may be discontinued or changed at any time.

(f) I hereby give ALSF consent to use my information listed in this application and to contact me to discuss the information contained in this form.

(g) I understand, or have expressed to the family, that I/they may be contacted by SuperSibs or affiliates regarding this program or related topics including, but not limited to, the opportunity to participate in research. These are optional programs and participants may opt out at any time.