EXHIBITW

(!)"! , First Name Last Name , do hereby A uth o ri ze the Relea s e of an y form of record s from my birth to the pre s en t date. includin g MEDI CAL / P SYC HOLOGI CAL/PS Y C H IA TRI C/ SUB STANCE A B USE information , including Registration Information , Admission a nd Discharge summaries , History & Physicals , Consultation reports , Operative reports , Laboratory reports , Pathology reports , Diagnostic reports , emergency room records , (including copies) as well as any other reports , evaluations , testing, assessments , histories , examinations, notes , prescriptions , treatment plans and instructions , limitations or any other form of document relating to the diagnosis and /or treatment of any real or s uspected conditions , including, but not limited to medical , psychiatric , ps ychological , alcoholism , substance abuse , sickle cell anemia, communicable diseases such as HI V/A ID S a nd s ex u a ll y r e la t ed di so rd e r , which is under your care, custody or control , pertaining to myself or any other person for whom I may legally consent."

(2)"1 do hereby further A uth o rize th e R ele ase o f an y fo rm of A RR EST o r C RI M I NA L R EC ORD S , C ORR EC TIO NAL or PROB ATIO N a nd /o r P A RO LE R EC ORD S or information in the possession of any community, c ity, coun ty, s t a te or federal pen a l in s titution , includin g juvenile facili t ies, m edi ca l facilitie s, m e ntal hea lth fa ciliti es, s ub s tan ce abu se tr e atment facilitie s and any court or pr o bation or par o le d e partment. It is my intention that this authorization include any and all information contained in my Central File, Unit File, Classification File, Grievance File , Gang Classification File , Medical Service File , Counseling, Education or other Treatment file or Probation / Parole Case or Supervision File including : Travel Cards , Incident reports , Disciplinary Reports , Educational or Training Records , Diagnostic , Assessment or Treatment records or Progress Reports for any Medical , Psychiatric or Educational services or other documents, data, reports , offense information (reports , summaries , records , statements , documents , notes) , case file documents or notes and /or reports or any other form of information "

(3)" 1 do hereby further A uthori z e the Relea se o f an y and all LIT IG A TIO N o r A TTORNEY files , records , and materials concerning my re pr ese nt a tion in an y and all c riminal o r civ il m atte r s, whether pending or closed I also expressly waive my Attorney-Client privilege and authorize my former attorney to discuss and give information regarding any aspect of his representation to my attorney or attorney representative listed below This release covers all materials in the possession ofmy attorney and / or his agents including, but not limited to : all files , memoranda, records , (including medical , psychiatric , substance abuse , school , employment, criminal , and military records) ; statements by witnesses or myself; whether given orally , taped or in writing ; and notes (including investigative and research notes) and notes of meetings and te lephone conversations concerning my representation "

(4)" 1 do hereby further A uthori z e the Relea s e o f an y form of E MPLOY MENT Record s includin g, applications, hiring documents, employment eligibility documents , disciplinary or termination documents , data , reports , evaluations , pay rates /sa lary rates or other compensation , as well as an y accident or incident information or other employment file documents and /or reports or any other form of information pertaining to my present and / or previous e mplo y men t hi s t o r y, unemployment , worker's compensation , Social Security Earnings information "

(5)"1 do hereby further A uthori ze the Relea s e o f an y form o f I NC O ME OR FINANC IAL Record s, including : payroll or earnings information , banking , checking , savings or loan deposit, withdrawal or payment records ; and an y Tax records or filings submitted to any State or Federal Internal Revenue Service or tax office ."

(6)"1 do hereby further A uthori z e the Relea s e o f an y form o f SC HOOL o r E D UCA TIO NAL Record s, documents , data , reports , disciplinary information (reports , summaries , records , statements) case file documents , Testing, Assessments , Evaluations and academic transcripts , Conference notes , or any other form of information pertaining to my present , and /or past educational activities including any of the previously listed information held separately pertaining to any S p eci a l Educati o n services that I may have received "

(7) " I do hereby A uthorize the Departm e nt of Famil y and Protec t ive S ervice s to release to my representative any and all info r mation , records , documents , or reports , that they have in their possession concerning myself or my child(ren) , including but not limited : All case files with documentation , caseworker notes (typed , handwritten) , case narratives , risk assessments , safety assessments , legal documents including affidavits , pleadings , orders of the court and / or affidavits ; Family Team Plans , Family Plans of Service (original and amended) , PHOTOGRAPHS , medical records , law enforcement records , school records , psychological and /or social evaluations , signed acknowledgments , drug test authorizations , drug test results , drug and /or alcohol assessments , Parental Child Safety Placements , Safety Plans , documents associated with a removal and /or placements , correspondence, collateral contact information , audio or video recordings I

Purp ose: These records are being requested in order to assist my Attorney in preparation of my defense in a legal matter.

R ev oc ati o n : This consent will expire 180 days from the fulfillment of this request by the provider. I further understand that I may revoke this authorization at any time by notifying the provider in writing The revocation will not affect any actions taken before the receipt of the written revocation

C opi es of thi s R equ est for Inform a ti o n: A copy of this request, either by facsim i le or by zerox , shall be treated as an original.

I understand that I am not required to sign this Authorization form in exchange for receiving treatment or payment from any treatment provider.

S u ch records should be released immediate ly upon request to my Attorney, Attorney

Name and address, or his rep rese n tative Mitigation Specialist name, address, phone, fax . l understand that if the recipient autho r ized to r eceive the information is not a cove red entity the released information may no longer be protected by fede r a l and state privacy regu lations.

Date of Birth :-------Signatu re

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