The Young at Heart Foundation is a non-profit organization whose fundraising efforts rely solely on the generous donors who support our cause and the children we help. Therefore, should you receive funds from our organization through the Young at Heart Foundation, we are asking that you allow us to use information regarding your situation and/or how our assistance impacted your lives and/or the patient for fundraising and other purposes. Sharing information about your situation may help others learn about our organization and its efforts and inspire them to become Program donors. Should you sign this information and photo release, The Young at Heart Foundation will use its best efforts to contact you to inform you when we use your personal information. We hope to keep you involved in the growth of our organization as a member of the Young at Heart family of beneficiaries. Should you choose not to sign the release; it will have no bearing on the outcome of your application.

I _________________, hereby agree to allow Young at Heart Foundation to utilize personal

information in this application for fundraising and other purposes.