Catholic Church of the Americas 601 Vintage Dr., #F244 Kenner, LA 70065 Name __________________________________________SSN _________________ DOB _______________ I hereby give permission to the Catholic Church of the Americas to:     ___ Release Information to     ____ Receive information from     ___ Exchange information with Agency or Person _________________________________________________________________________ Address:          ____________________________________________________________________________                        ____________________________________________________________________________ For the purpose of arranging the following service: _______________________________________________ The specific information to be disclosed is:     ___Application Data        ___Third party school records        ___Psychological Tests/Records     ___Reference Data        ___Other (Specify) __________________________________________________ I hereby release the Catholic Church of the Americas from liability which may arise as a result of the used information disclosed by this authorization, should it be presumed that such information is later used to my detriment. Signature _________________________________________________ Date __________________________ Witness Signature __________________________________________ Date __________________________