Health

I affirm that the statements that I have made above are accurate and true to the best of my knowledge and belief. I hereby request the assistance of the La Porte County Branch of the NAACP in seeking a remedy to the situation described above. I hereby authorize the officers of the La Porte County NAACP Branch 3061 to have access to information and documents, which are relevant to my claim of discrimination described above. I understand that once a referral has been made to a volunteer, community agency or private attorney, the La Porte County NAACP Branch 3061 WILL NOT BE RESPONSIBLE for handling this matter. In fact, I further understand that by signing this document, I am agreeing to HOLD the La Porte County NAACP Branch 3061 harmless for any and all damages arising as a result of my case being mishandled, negligently handled or improperly handled in any way.