Title: Supervisor’s OK
Author: Computer Support Services

HAMLINE UNIVERSITY SCHOOL OF LAW
TRIAL PRACTICE CLINIC
AUTHORIZATION FOR THE RELEASE OF INFORMATION

I, ________________________________________, authorize and instruct __________________________________________________________________________________________
to release to Hamline University School of Law, Trial Practice Clinic, 1536 Hewitt Avenue, St. Paul, Minnesota, 55104 (651-523-2898), and any of its employees, including __________________________________________ and _________________________________ the following information: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
The purpose and use for which the information is requested is for evaluation of my legal rights and possible legal representation.

I understand that this information will be used by Hamline University School of Law, Trial Practice Clinic, solely for the purpose and in the manner specified above, and will not be disclosed to other sources unless specifically authorized by law.  I have been informed that I may refuse to authorize the release of this information and have had explained to me the consequences of my refusal to release the information.

This authorization will remain in full force and effect, subject to my right to revoke at any time, until_________________ (date certain, not longer than one year).

This authorization has been translated to me in my native language by___________________________________ and I understand its contents.

A photocopy of this authorization shall be considered as valid as the original.

Social Security number _________________________________ Date of Birth ___________________

Maiden or other name ____________________ _______________________________________________________________________________
Dated _________________________________	_______________________________________________
							Signature of Client