Juvenile Services Program Information Release Name of Agency/Individual Releasing Information(Required)Address of Agency/Individual Releasing Information(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Information to release:(Required) School record(s) to include: counseling statements, behavioral issues, grades, progress, and IEP Court records Medical records Mental health and diagnostic assessments Treatment/service plan(s) Progress reports Substance abuse assessments Social history/assessments Law enforcement agency records Tribal enrollment verification Tribal Social Services/Indian Child Welfare Other Other information to release:(Required)Method of release:(Required) Written Verbal Fax Email Audio Video I, the below-named, authorize the above-named agency/individual to release information to and exchange information with the Wichita & Affiliated Tribes Juvenile Services Program, for the purpose of receiving their program services as indicated above. I understand my records are protected under Federal and State laws and cannot be released without my written permission, unless otherwise provided. I understand all my information shall remain confidential in accordance to Federal and State laws. I hereby authorize the release and/or exchange of the above identifying information from my records. This consent is subject to revocation by me at any time, except to the extent that the program which is to make this disclosure has already taken action in reliance upon it. The Juvenile Services Program may not condition treatment of me on whether or not I revoke this release of information. This release will remain in effect for one year from the date of my signature. This authorization includes the use and/or disclosure of information concerning HIV testing or treatment of AIDS or AIDS-related conditions, any drug or alcohol abuse, drug-related conditions, alcoholism, and psychiatric/psychological conditions to the above-mentioned entities.Printed Name of Authorized Person(Required) First Last Date(Required) Month Day Year Signature of Authorized Person(Required)Signature of Parent/GuardianIf the authorized person is a minor, a parent or guardian must sign.
