I, _____________________________________________, am not habituated or addicted to depressants, stimulants, narcotics, alcohol
or other substances nor do I have a physical or emotional condition that may alter my behavior, interfere with the performance of my
duties or pose a potential risk to patients. The responses above are true to the best of my knowledge. I understand that any omissions,
error and/or misstatement of facts may be grounds for termination of my Bright Future for the Children LLC contract/employment.