Please describe the diagnosed Illness.
I understand and agree:
1) That no promises or assurances whatsoever have been made to me by any representative of the Let There Be Mom organization regarding providing any services to me or my family;
2) That granting services of any kind is contingent upon approval by the Let There Be Mom organization and my physician, as well as full compliance with all conditions,
qualifications, and restrictions designated by the Let There Be Mom organization;
3) That all individuals with parental or custodial rights for the children must approve participation with the Let There Be Mom organization and sign all necessary documents before services can begin; and
4) That full disclosure of anyone having power-of-attorney over me must be made and they must complete the appropriate documents before the Let There Be Mom
organization will consider offering services to me. I promise that the information provided by me is true and complete to the best of my knowledge.