Child Custody Information Release Consent
Child's Name
Date of Birth
Child’s ID/Case Number
Parent/Guardian Name
Relationship to Child
Name of Organization/Individual Releasing Information
Name of Recipient
Recipient Contact Details
Type of Information to be Released
Purpose of Release
Consent Expiration Date or Event
Additional Instructions/Limitations
By signing below, I authorize the release of the above-specified information regarding the minor named above. I understand that I may revoke this consent in writing at any time, except to the extent that action has already been taken in reliance upon it.
Signature of Parent/Guardian
Date