"Infant Release Authorization Form" - Nevada

Infant Release Authorization Form is a legal document that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada.

Form Details:

  • Released on May 1, 2018;
  • The latest edition currently provided by the Nevada Department of Health and Human Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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INFANT RELEASE AUTHORIZATION
To be submitted by the hospital to the Nevada State Division of Child and Family Services BEFORE physical custody of a child
is released to a person other than a parent or relative.
I. PARENT’S AUTHORIZATION (To be filled out completely before parent signs)
I,_________________________________________________, the mother of ____________________________________________
Born to me at ________________________________________ Hospital on _____________________________________authorize
Date
said hospital to release my child to ______________________________________________________________________________
Name
___________________________________________________________________________________________________________
Permanent Address: Street
City
State
Zip
For the purpose of ___________________________________________________________________________________________
e.g.: adoption, transfer to another hospital, foster care, boarding care pending adoption
This consent is for the release of my child from the hospital only and does not constitute a consent or
relinquishment of my child for adoption.
Dated this _________ day of ___________________, 20_________
_________________________________________________
Signature of mother (even if minor) or authorized person having legal custody of child
Witness ________________________________________________
_________________________________________________
Witness Signature
Permanent address of mother or guardian
II. ACKNOWLEDGEMENT BY PERSON(S) RECEIVING CHILD
We (I) have on this _________ day of ___________________, 20_________ received from ________________________________
Hospital
The child ___________________________________________ for the purpose of ________________________________________
Witness ________________________________________________
_________________________________________________
Signature(s) or person(s) receiving child
Identification of person (s) receiving child:
_________________________________________________
Driver’s Lic. No. __________________________________________
_________________________________________________
So. Sec. No. _____________________________________________
_________________________________________________
Permanent address: Street
City
State
Other __________________________________________________
III. REPORT OF HOSPITAL
___________________________________________________________________________________________________________
Name of hospital
Street
City
State
Name of mother _______________________________ Current address________________________________________________
Date of arrival ______________________________________ Date of discharge__________________________________________
Attending physician __________________________________________________________________________________________
Name
Address
Name of
Child’s father _________________________________ Address _______________________________________________________
Child’s name ______________________________________ Sex _________ Date Child released_____________________________
_________________________________________________
Signature of administrator or designated representative
Mail or fax a copy to:
DIVISION OF CHILD AND FAMILY SERVICES, Social Services Adoption Specialist
4126 Technology Way, 3rd Floor, Carson City, NV 89706
Fax: (775) 684-4456
Revised 5.2018
INFANT RELEASE AUTHORIZATION
To be submitted by the hospital to the Nevada State Division of Child and Family Services BEFORE physical custody of a child
is released to a person other than a parent or relative.
I. PARENT’S AUTHORIZATION (To be filled out completely before parent signs)
I,_________________________________________________, the mother of ____________________________________________
Born to me at ________________________________________ Hospital on _____________________________________authorize
Date
said hospital to release my child to ______________________________________________________________________________
Name
___________________________________________________________________________________________________________
Permanent Address: Street
City
State
Zip
For the purpose of ___________________________________________________________________________________________
e.g.: adoption, transfer to another hospital, foster care, boarding care pending adoption
This consent is for the release of my child from the hospital only and does not constitute a consent or
relinquishment of my child for adoption.
Dated this _________ day of ___________________, 20_________
_________________________________________________
Signature of mother (even if minor) or authorized person having legal custody of child
Witness ________________________________________________
_________________________________________________
Witness Signature
Permanent address of mother or guardian
II. ACKNOWLEDGEMENT BY PERSON(S) RECEIVING CHILD
We (I) have on this _________ day of ___________________, 20_________ received from ________________________________
Hospital
The child ___________________________________________ for the purpose of ________________________________________
Witness ________________________________________________
_________________________________________________
Signature(s) or person(s) receiving child
Identification of person (s) receiving child:
_________________________________________________
Driver’s Lic. No. __________________________________________
_________________________________________________
So. Sec. No. _____________________________________________
_________________________________________________
Permanent address: Street
City
State
Other __________________________________________________
III. REPORT OF HOSPITAL
___________________________________________________________________________________________________________
Name of hospital
Street
City
State
Name of mother _______________________________ Current address________________________________________________
Date of arrival ______________________________________ Date of discharge__________________________________________
Attending physician __________________________________________________________________________________________
Name
Address
Name of
Child’s father _________________________________ Address _______________________________________________________
Child’s name ______________________________________ Sex _________ Date Child released_____________________________
_________________________________________________
Signature of administrator or designated representative
Mail or fax a copy to:
DIVISION OF CHILD AND FAMILY SERVICES, Social Services Adoption Specialist
4126 Technology Way, 3rd Floor, Carson City, NV 89706
Fax: (775) 684-4456
Revised 5.2018