Fallen Troops Grant Application

Please print and sign this application on the bottom of the last page. Attach a photocopy
of the front and back of your Military Privilege Card, a copy of the death certificate
or other military notification of death, and a photo of the dependents) listed below
and mail to:

Fallen Troops Foundation
21-C East Mellen Street
Hampton Virginia 23663

Or, if you prefer, you can request an application by writing to the above address.

Your Information

Name: __________________________________________

Address: ________________________________________

Daytime Phone: __________________ Evening Phone: _________________

Email Address:______________________________________

Your Relationship to the Fallen Troop: ___________________________

Children (under age 21) or Adult dependent under your legal custody who qualify as a
dependent of the Fallen Troop for IRS purposes.

Full Name: ____________________________________ Age: ___

Full Name: ____________________________________ Age:____

Full Name: ___________________________________ Age:_____

Fallen Troop's Information

Name: ________________________________

Military Branch: _______________________ Rank:__________

Date and Event Resulting in Loss: _________________________

_____________________________________________________

Casualty Assistance Officer Name and Phone#:________________
_______________________________________________________

Other Information

Please provide planned use of funds for grant: __________________

________________________________________________________

In consideration of my family’s receipt of funds from the Fallen Troops Foundation, and on behalf of my
minor children and me, I hereby authorize the foundation and it's employees, agents, licensees, successors
and assigns and each of them (collectively "Fallen Troops") to take pictures and interview my family and
me and to put media representatives in contact with me to take pictures and conduct such interviews, to
further the charitable purposes of Fallen Troops, in accordance with the specified below.

On my own behalf and on the behalf of my minor children, I hereby:

Grant to Fallen Troops, to the fullest extent possible under law, all right, title, and interest in and to
any photographs, pictures, likenesses, recordings, transmissions, interviews, studies, publicity, advertising
and promotional material, and all other expression or work created under this agreement, including without
limitation the right to use, re-use, publish, distribute, reproduce, display, modify, and create derivative
works based on all work or expression created under this Agreement, in all media now known or hereafter
developed or invented.

Authorize Fallen Troops, to use my and/or their names, signatures, photographs, pictures, physical
likenesses, and recordings of my and/or their voices in any manor desired by Fallen Troops, on and in
connection with any work or expression created under this Agreement, including but not limited to use in
and for studies, illustrations, publicity, advertising, and promotions.

Neither I nor my minor children shall have any right, title, or interest in any of the foregoing, including but
not limited to any rights to register, hold, and renew any copyright for or incorporating any such creations.

I agree that any photograph that I provide to Fallen Troops may be used under the terms of this Agreement
as if it had been taken by Fallen Troops.

Fallen Troops may sell, assign, license, or otherwise transfer all rights granted to it hereunder in furtherance
of its charitable purposes.

On behalf and on behalf of my minor children, named, I fully and forever release and discharge Fallen
Troops of and from any and all claims, demands, actions, causes of action, suits, controversies, and
liabilities of every kind and nature accruing to me or to them and arising directly or indirectly from the use
of my and/or their names, signatures, photographs, pictures, physical likenesses, or recordings or my and/or
their voices. In addition, I agree that the rights released by me and by the minor children named in this
application include, without limitation, all rights under Virginia Civil code, all claims based on the right to
publicity of living persons and survivors of deceased persons, and all claims based on invasions of privacy,
libel, slander, and infringement of copyright.

I understand and agree that this Agreement shall be effective and binding upon me and my minor children
forever from the date hereof, and that it shall be applicable throughout the world.

I have read and understood all of the above, and I agree to all of its terms, on my behalf and on behalf of m)
minor children.

Signature_______________________________ Date_______________________

Fallen Troops Foundation
21-C East Mellen Street - Hampton Virginia 23663 (757) 224-04180 Fax (757) 722-6700
Toll Free 1-866-4 FALLEN