I certify that the information on this request for assistance is accurate to the best of my knowledge. I understand that my willful misstatement of the facts may cause my forfeiture of any assistance. I hereby approve the release of all information that is determined pertinent to my request, including but not limited to phone number, financial information, class schedules and grades, disability determination, and any other related information that would result in assistance with my request. I hereby acknowledge that this consent is voluntary.
Signature of Student/Participant
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