Fill and Sign the Consent Release or Refusal to Contact Form

JDF 346 R9/00 CONSENT RELEASE OR REFUSAL TO CONTACT District Court  Denver Juvenile Court_________________________________________ County, ColoradoCourt 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 SignatoryI, _______________________________________________________________________________, 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 DateConfidential Intermediary Date_________________________________________________________________________________________________________________________________Address of SignatoryI certify that a signed copy of this Consent Release or Refusal to Contact was received in the __________________Court, ________________County, Colorado._____________________________________________ ___________________________________________DateSignature of Clerk