I am a Non-Minor Dependent of the Los Angeles Juvenile Dependency Court. I hereby give my permission for CASA of Los Angeles (CASA) to inspect and copy records pursuant to CAL. WIC CODE SEC. 107 (a) and (b). This authorization shall include the inspection and copying of records relating to my dependency case from any agency, hospital, school, organization, division or department of the state, physician and surgeon, nurse, other health care provider, psychologist, psychiatrist, police department or mental health clinic.

I understand that I may revoke or modify my consent for the CASA to copy and inspect my records pursuant to CAL. WIC CODE SEC. 107 (a) and (b) at any time after signing this consent form. My revocation may be given orally to my court appointed CASA or in writing. Any written revocation shall be sent to the office of the CASA of Los Angeles at 201 Centre Plaza Drive, Room 1100, Monterey Park, CA 91754.