My digital signature below certifies that I have read this statement and that there are no misrepresentations, omissions, or falsifications in the below statement or information. This statement is true, complete, and correct to the best of my knowledge, belief, and understanding. I understand that any false or misleading information contained herein will subject me to the penalties as prescribed by 18 Pa. C.S.A. § 4904, relating to Unsworn Falsification to Authorities, and/or other applicable offenses. Furthermore, my digital signature below shall serve as authorization to release any information and records, including medical, necessary to investigate this complaint and releases all parties from any civil claims.