IMG_1325 2-2

I certify that the information provided herein, and in any other related documents and/or representations, are true and correct to the best of my knowledge, and I understand that access to any and all HCAP premises, programs and/or services through misrepresentation or fraud may be punishable under HCAP policies, procedures, or practices including, but not limited to, refusal of services, at the sole discretion of HCAP. I further understand that a false statement under these forms or other communications can also expose me to civil and/or criminal liability that may include financial obligations or criminal penalties. I understand that this information will be used only to determine if I may gain entry onto any and all HCAP premises, and/or to determine if I and my family are eligible for any and all HCAP services, and will not be released to non-HCAP sources without my prior knowledge and written consent. HCAP does not discriminate on the basis of race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age (40 or older), disability and genetic information (including family medical history), or reprisal or retaliation for prior civil rights activity in any program or activity conducted.