Senior Vouher Test



    Phone Number                                                     Email

    Source of Income


    Line 150 of T1 General *Mandatory*

    If selected other, please explain

    I hereby grant Community Alliance for Support and Empowerment (C.A.S.E.) permission to use photographs for the purposes of web-based publications, print advertisements and organization bulletins and affirm that such release to C.A.S.E does not constitute any form of compensation, including royalties arising from the photographs, to my benefit.

    I hereby hold harmless, release, and forever discharge Community Alliance for Support and Empowerment and it's affiliates, including third parities from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

    Signature: I hereby declare all information disclosed in this form to be true.

    Date Signed