Fill and Sign the Consent Release or Refusal Colorado Form

 District Court  Denver Juvenile Court _________________________________________ County, Colorado Court Address: IN THE MATTER OF THE ADOPTION OF: AND CONCERNING : , Petitioner COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail: FAX Number: Atty. Reg.#: Case Number: Division Courtroom CONSENT RELEASE OR REFUSAL TO CONTACT I , __________________________________________________________________________, CONSENT TO CONTACT with my _________________________________________________________________________________(relationship). My legal name is: _____________________ My legal birth name was: Date of Birth : _______ I agree to the following form of contact:  exchange of correspondence  telephone call  personal meeting  other (specify) _________________________________________ I state that my consent is voluntary and informed, and I release the confidential intermediary, the training organization, the Court and any agency from any liability resulting from this contact. ___________________________________________________ ___________________________________________ Signed Date Confidential Intermediary Date _________________________________________________________________________________________________________________________________ Address of Signatory I , _______________________________________________________________________________, REFUSE CONTACT with my __________________________________________________________________________________(relationship). My current legal name is: ____________________ My legal birth name was: Date of Birth: I acknowledge receipt of information about the Colorado Voluntary Adoption Registry for my use in the event I should ever desire to have contact with this individual. It is my present desire that the records remain sealed and my anonymity be preserved. _ ____________________________________________ ___________________________________________ Signed Date Confidential Intermediary Date _________________________________________________________________________________________________________________________________ Address of Signatory I certify that a signed copy of this Consent Release or Refusal to Contact was received in the __________________Court, ________________County, Colorado. _____________________________________________ ___________________________________________ Date Signature of Clerk JDF 346 R9/00 CONSENT RELEASE OR REFUSAL TO CONTACT