Name *

First Name

Last Name

Phone

(###)

###

####

CONSENT TO ELECTRONIC TRANSMISSION *

By checking this box, you are consenting to to receive and send information, including but not necessarily limited to questionnaires, rules and procedures, payment information, and other information regarding the Haven Homes Foundation, via electronic transmission (fax and/or e-mail), until such time as this consent is revoked in writing. Please see Member Consent to Electronic Transmission for further details.