Juvenile Justice Collaboration
Release of Information
Youth/Client Name:
Date of Birth:
Parent/Guardian Name (if applicable):
Agency/Organization to Release Information:
Type of Information to be Released:
Purpose of Release:
Agency/Organization Receiving Information:
Expiration Date or Event:
Limitations or Exclusions (if any):
Additional Instructions or Information:
Signature of Youth/Client
Date:
Signature of Parent/Guardian
Date:
Witness/Staff Signature
Date: