Child Protective Services Interagency Release Form

Child's Name

Date of Birth

Case Number

Parent/Guardian Name Parent/Guardian Address Agency/Organization to Release Information TO Agency/Organization to Release Information FROM Information to be Released Purpose of Release Duration of Consent

I understand that I may revoke this authorization at any time, except to the extent that action has already been taken. Further disclosure of this information by the recipient is not authorized unless permitted by applicable law.

Signature of Parent/Guardian

Date

Signature of Witness

Date