I/We give the Demetricia C. Patterson Foundation, its staff and associated members my/our permission and approval to contact any and all agencies and businesses as required by their policies and procedures, to assist me/us with their services.

Further, I/we hold all agencies and business harmless in the release of our personal information to the Patterson Foundation.

Signature (Applicant's Name):      

Signature (2nd Applicant's Name - if applicable):

Date: