Consent to Release Information

This consent will allow the release of information about you, your child, or your family to individuals and/or organizations outside of our agency. Please read it carefully before initialing and signing it. If you have questions about this form, do not hesitate to ask.

Please remember that:

Signing this consent is completely voluntary and there are no negative consequences for refusing to sign
Consent is valid for one year from the day this document is signed)
You may withdraw your consent at any time

(participant or guardian) give consent for Pacific Community Resources Society to release information as listed below:

Person or Position (If applicable)	Organization	Information to Release	Participant Initials

Name of Child (If applicable)

Consent Statement

I give consentI do not consent

Participant/Guardian Name

Date of Consent Given

*If participant refuses to sign, please include date and name of staff member who discussed consent with participant

SF Agency Participant file

Intake ID

Consent Form Type

Contact Information