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8585 PGA Drive, Suite 103 • Walled Lake, Michigan 48390 Phone (248)960-9291 • Fax (248)960-9289 AUTHORIZATION TO RELEASE SCHOOL INFORMATION School Name: School Address: Student Name: Date of Birth: S.S. #: I, the undersigned hereby authorize the above named facility, its directors or agents, to disclose information and records of the person identified above, which includes information that may be stored in a paper and/or electronic format. I authorize my information to be released to: Legal Eagle Copy Service, LLC 8585 PGA Drive, Suite 103 Walled Lake, MI 48390 For the purpose of legal discovery, reproduction and distribution in the course of litigation. This authorization shall permit the listed recipient to examine, photocopy and/or receive any records or information pertaining to the above named individual. Specific records to be disclosed are those records in your possession pertaining to the above mentioned person, this includes, but is not limited to, transcripts, attendance records, grade reports, testing data, MEAP and ACT scores, all files, performance reviews, physical and psychological records. I understand that the information used or disclosed pursuant to this authorization may be disclosed and reproduced by the recipient through the course of the pending litigation and may no longer be protected by the Federal Privacy Rules or other such applicable laws. The forgoing authorization shall continue in force for 120 days from date of signature, or until revoked by me in writing. I understand that I may revoke this consent at any time, in writing to the facility and recipient identified above, except to the extent that action has already been taken to comply with it. This authorization is voluntary. I understand that the facility will not base treatment, payment, enrollment, or eligibility for benefits on my signing this document. A copy of this authorization shall be as valid as the original. Date: ______________ Signature: ______________________________________ Personal Representative/Parent/Legal Guardian: _______________________ Subscribed and sworn to before me this _____ day of _______, 20______ Notary Public: __________________________________________________ and/or

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8585 PGA Drive, Suite 103 • Walled Lake, Michigan 48390Phone (248)960-9291 • Fax (248)960-9289

AUTHORIZATION TO RELEASE SCHOOL INFORMATION

School Name: School Address:

Student Name:Date of Birth:S.S. #:

I, the undersigned hereby authorize the above named facility, its directors or agents, to disclose informationand records of the person identified above, which includes information that may be stored in a paper and/orelectronic format. I authorize my information to be released to:

Legal Eagle Copy Service, LLC8585 PGA Drive, Suite 103Walled Lake, MI 48390

For the purpose of legal discovery, reproduction and distribution in the course of litigation. Thisauthorization shall permit the listed recipient to examine, photocopy and/or receive any records orinformation pertaining to the above named individual.

Specific records to be disclosed are those records in your possession pertaining to the above mentionedperson, this includes, but is not limited to, transcripts, attendance records, grade reports, testing data, MEAPand ACT scores, all files, performance reviews, physical and psychological records.

I understand that the information used or disclosed pursuant to this authorization may be disclosed andreproduced by the recipient through the course of the pending litigation and may no longer be protected bythe Federal Privacy Rules or other such applicable laws.

The forgoing authorization shall continue in force for 120 days from date of signature, or until revoked by mein writing. I understand that I may revoke this consent at any time, in writing to the facility and recipientidentified above, except to the extent that action has already been taken to comply with it.

This authorization is voluntary. I understand that the facility will not base treatment, payment, enrollment, oreligibility for benefits on my signing this document.

A copy of this authorization shall be as valid as the original.

Date: ______________

Signature: ______________________________________

Personal Representative/Parent/Legal Guardian: _______________________

Subscribed and sworn to before me this _____ day of _______, 20______

Notary Public: __________________________________________________

and/or

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