(Please note: All recipients must sign the following release on the application page)

I agree to allow The C.H.A.I.N. Fund, Inc. to verify my account (s) information for the sole purpose of processing my application for financial assistance. The C.H.A.I.N. Fund Inc. agrees to use this information for the purpose of determining eligibility of assistance only. Any and all information pertaining to my medical status and personal information will be regarded Strictly Confidential.


Release Form (Please note: The following is Mandatory to receive assistance.) I agree to allow The C.H.A.I.N. Fund, Inc. to utilize anonymous testimonials and or likenesses of me for the sole purpose of promoting and obtaining additional funding for The C.H.A.I.N. Fund, Inc. I understand that these promotional items may include but not limited to Video, and quotes in print form, using only my initials and my geographical location, ie; state only.


The C.H.A.I.N. Fund, Inc. agrees to preserve the confidentiality and Privacy of our clientele by only using the aforementioned testimonials/likenesses as examples of how individual and or families are supported by The C.H.A.I.N. Fund, Inc. The use of such will be done solely on expressed written release from me at that time. By signing this release form I state that I fully understand and agree to its contents.