College Legal Package — Client Intake

Step 2

The student (principal)

Full legal name (as on government ID) *

Date of birth *

Must be 18+ at signing.

Cell phone

Email

ParishCounty of residence

Permanent home address

LouisianaMississippi college / university and campus city

Step 3

The agent(s)agent(s) / attorney(s)-in-fact

The student appoints these people to act on the student’s behalf — they are not signing for the student.

Primary agent — full legal name *

Relationship to student

Address

Phone

Email

Co-agent (optional)

Full legal name

Relationship

Phone

Email

If there are two agents, may they act: Independently — either may act alone Jointly — both must act together

Successor / alternate agent (optional)

Name

Relationship

Phone

Step 4

Financial power of attorney

When should the financial mandate take effect? Immediately — so the agent can help with everyday problems right away Only if the student becomes disabled (conditional procuration) — note: will not help with routine bank, lease, school-account, or tax issues

When should the durable power of attorney take effect? Immediately & durable — effective now and unaffected by later incapacity Springing — effective only upon the student’s disability/incapacity (will not help with routine problems)

Powers to grant the agent Manage bank / credit-union accounts Deal with the university bursar, student-accounts, financial-aid, and housing offices Enter, modify, or end a residential lease Handle vehicle registration, title, and insurance Receive and manage mail and packages Access and manage online accounts as permitted by law Sign tax returns and deal with taxing authorities

Any powers to withhold? (optional)

Step 5

Health-care decisions & medical access

Is the health-care agent the same person as the financial agent above? Yes No

If different, name the health-care agent(s)

HIPAA — who may receive the student’s medical information? (may be more people than the agent)

Advance directive (Louisiana)

End-of-life wishes — artificial nutrition & hydration May be withheld in a terminal, irreversible condition Should be provided

Upon death, I wish to be an organ/tissue donor (Donate Life Louisiana)

Advance Health-Care Directive (Mississippi — Miss. Code § 41-41-209)

In Mississippi this single directive combines the medical power of attorney, end-of-life instructions, organ donation, and primary physician.

End-of-life instruction Do not prolong life if the burdens of treatment would outweigh the benefits Prolong life as long as possible within accepted standards

Artificial nutrition & hydration Withhold, consistent with the choice above Provide

Upon death, I wish to donate organs/tissue (Mississippi Organ Recovery Agency)

Primary physician (name & phone)

Wallet-card medical info (for the student to carry)

Allergies

Chronic conditions

Current medications

Primary physician

Health insurer (no member ID / account numbers)

Step 6

School records (FERPA)

Who may access the student’s education records?

Scope

School the authorization is directed to

Step 7

Logistics

Where will the executed originals be kept, and who holds copies?

Preferred signing date / time

Second student in the family? (sibling rate)

Form completed by

Date

I understand these are legally effective documents, that the student is the person granting authority, and that they are not effective until properly signed, witnessed, and/or notarized as required by law. I have not included any Social Security or account numbers. *

Client Intake Form

Which state is the school in?

The student (principal)

The agent(s)agent(s) / attorney(s)-in-fact

Co-agent (optional)

Successor / alternate agent (optional)

Financial power of attorney

Health-care decisions & medical access

Advance directive (Louisiana)

Advance Health-Care Directive (Mississippi — Miss. Code § 41-41-209)

Wallet-card medical info (for the student to carry)

School records (FERPA)

Logistics

Thank you — your intake has been received.