Guardian ad Lietem Registry Release Page 1 of 1 CLARK COUNTY SUPERIOR COURT GUARDIAN AD LITEM REGISTRY RELEASE (To Be Enclosed With Your Application) Date: / / LICENSE NUMBER To: Washington State Bar Association Washington State Medical Association Washington State Nursing Commission Washington Board of Psychology Washington State Department of Licensing Other: I, , hereby authorize you, for the purpose of my application and/or work as Guardian ad Litem for the Clark County Superior Court, to release information to and discuss such information with: Clark County Superior Court PO Box 5000 Vancouver, WA 98666-5000 This RELEASE includes, but is not limited to, all records and information concerning any official disciplinary action or any pending active investigation you have with regard to me. Signature Printed Name Street Address City/State/Zip Code Telephone No./Fax No. American LegalNet, Inc. www.FormsWorkFlow.com