I authorize the Emily Whitehead Foundation and its agents and representatives to contact my child's medical provider in order to verify my child’s cancer diagnosis and CAR-T cell therapy treatment.

I authorize the above named medical provider to release to Emily Whitehead Foundation and its agents and representatives any information and medical records deemed necessary by Emily Whitehead Foundation to complete its verification of my child’s cancer diagnosis and CAR-T cell therapy treatment.

I acknowledge that Emily Whitehead Foundation will pursue and is entitled to restitution for a grant if it is determined that the information submitted on this application is false.

I authorize the Emily Whitehead Foundation and its agents and representatives to contact my child's
medical provider in order to verify my child’s cancer diagnosis.

I authorize the above named medical provider to release to Emily Whitehead Foundation and its agents and representatives any information and medical records deemed necessary by Emily Whitehead Foundation to complete its verification of my child’s cancer diagnosis.

I acknowledge that Emily Whitehead Foundation will pursue and is entitled to restitution for a grant if it is determined that the information submitted on this application is false.