The Cause Foundation General Release Form printable pdf download

The Cause Foundation General Release Form

THE CAUSE FOUNDATION

GENERAL RELEASE FORM

I,___________________________________________________________AUTHORIZE

THE FOLLOWING PERSON(S) TO RELEASE INFORMATION TO

REPRESENTATIVE(S) OF THE CAUSE FOUNDATION.

• NAME/PHONE/FAX________________________________________________

___

• ORGANIZATION/TITLE____________________________________________

___

(THIS CAN BE PHYSICIAN, BANKING INSTITUTION AND ACCOUNT #,

EAP,

ETC.)

THE INFORMATION RELEASED SHALL BE FOR THE PURPOSE OF OBTAINING

A CAUSE FOUNDATION GRANT.

COMMENTS:___________________________________________________________

_______________________________________________________________________

THIS RELEASE SHALL BE IN EFFECT FROM _____________ TO ______________

I UNDERSTAND THAT I CAN REVOKE THIS RELEASE AT ANY TIME.

____________________________________

SIGNATURE

____________________________________

DATE

The Cause Foundation General Release Form