Release Form

Soler and Peters (1993) state that a release form generally contains the following information:

• "The name of the person who is the subject of the information.

• The name of the person, program, or agency sharing the information.

• The name of the person, program, or agency with whom the information will be shared.

• The reasons for sharing the information.

• The kind of information that will be shared.

• The signature of the person who is the subject of the information.

• The date the release is signed.

• A statement that the release can be revoked any time by the subject of the information.

• An expiration date for the release or a specific event (such as the end of the school year) that will terminate the release.

• A notice stating that the subject of the information has a right to receive a copy of the release." (p. 12)

Sample release forms from several collaboratives follow:

• Consent to Participate and Authorization to Share Information from the Bay Point/West Pittsburg Family Service Center, Bay Point, California

• Comprehensive Release Form from the New Beginnings Center for Children and Families, San Diego, California

• Case Conference Parent/Guardian Consent Form from the Fulton County KIDS Project, Fulton County, Kentucky

• Authorization for Release and Exchange of Information from Youth Services Teams in Linn County, Oregon

• Consent for Release of Confidential Information relating to alcohol- or drug-abuse treatment services

  References