"Consent to Release Information" - Florida

Consent to Release Information is a legal document that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida.

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Download "Consent to Release Information" - Florida

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Access to Juveniles & Juvenile Information
STATE OF FLORIDA
Attachment 2
DEPARTMENT OF JUVENILE JUSTICE
Consent to Release Information
The confidentiality of all juveniles in the custody of or programs contracted to the Department of Juvenile Justice is
protected. The release of any information, images or recordings that would breach that confidentiality will be granted
upon proper execution of this form and approval by the Secretary for the Department of Juvenile Justice.
This release does not authorize the release of any medical information.
Informed consent for the making of photographs, videotapes and or sound recordings of
_____________________________________________________________
is hereby granted
not granted
.
Permission to use these images or sound recordings is given to the Florida Department of Juvenile Justice for the
purpose of public information, education or training.
I authorize the Department to release to the public, including the news media, information regarding the above-
named youth. This shall include release of name and other identifying information, as well as photographs,
videotapes or sound recordings.
I understand that the Department and its agents may use this material for an indefinite period of time. This authorization
can be revoked by written statement mailed to the Communications Office, Department of Juvenile Justice, 2737
Centerview Drive, Tallahassee, Florida 32399-3100. If revoked, the Department shall not be required to recall affected
publications, photographs, videotapes, slides or sound recording then in use.
Signature____________________________________________ Age_____ Date___________________________
Address_____________________________________________________________________________________
City________________________ State_______ Zip Code______________ Phone Number (
)______________
Parent/Guardian Signature____________________________________________Date________________________
Print Name______________________________________________________________________________________
Address if different from above_____________________________________________________________________
City________________________ State_______ Zip Code_________Phone Number (
) __________________
DJJ staff or contracted program staff receiving this form:________________________________________________
Title:_______________________ Name of Program_______________________________________________
Address: _________________________________________Phone Number (
)_________________________
The original executed form must be forwarded to the Communications Office for the Secretary’s approval; a copy must be
filed with appropriate circuit regional/or program office and a copy given to the juvenile’s parent or guardian executing the
form.
Date submitted to Communications Office: ____________________Recipient_____________________________
FAX Number: (850) 921-5907
 APPROVED  NOT APPROVED Date:
Secretary or Designee:__________________
2737 CENTERVIEW DRIVE
TALLAHASSEE, FLORIDA 32399-3100
Access to Juveniles & Juvenile Information
STATE OF FLORIDA
Attachment 2
DEPARTMENT OF JUVENILE JUSTICE
Consent to Release Information
The confidentiality of all juveniles in the custody of or programs contracted to the Department of Juvenile Justice is
protected. The release of any information, images or recordings that would breach that confidentiality will be granted
upon proper execution of this form and approval by the Secretary for the Department of Juvenile Justice.
This release does not authorize the release of any medical information.
Informed consent for the making of photographs, videotapes and or sound recordings of
_____________________________________________________________
is hereby granted
not granted
.
Permission to use these images or sound recordings is given to the Florida Department of Juvenile Justice for the
purpose of public information, education or training.
I authorize the Department to release to the public, including the news media, information regarding the above-
named youth. This shall include release of name and other identifying information, as well as photographs,
videotapes or sound recordings.
I understand that the Department and its agents may use this material for an indefinite period of time. This authorization
can be revoked by written statement mailed to the Communications Office, Department of Juvenile Justice, 2737
Centerview Drive, Tallahassee, Florida 32399-3100. If revoked, the Department shall not be required to recall affected
publications, photographs, videotapes, slides or sound recording then in use.
Signature____________________________________________ Age_____ Date___________________________
Address_____________________________________________________________________________________
City________________________ State_______ Zip Code______________ Phone Number (
)______________
Parent/Guardian Signature____________________________________________Date________________________
Print Name______________________________________________________________________________________
Address if different from above_____________________________________________________________________
City________________________ State_______ Zip Code_________Phone Number (
) __________________
DJJ staff or contracted program staff receiving this form:________________________________________________
Title:_______________________ Name of Program_______________________________________________
Address: _________________________________________Phone Number (
)_________________________
The original executed form must be forwarded to the Communications Office for the Secretary’s approval; a copy must be
filed with appropriate circuit regional/or program office and a copy given to the juvenile’s parent or guardian executing the
form.
Date submitted to Communications Office: ____________________Recipient_____________________________
FAX Number: (850) 921-5907
 APPROVED  NOT APPROVED Date:
Secretary or Designee:__________________
2737 CENTERVIEW DRIVE
TALLAHASSEE, FLORIDA 32399-3100