Authorization to Release Home Study

Authorization to Release Home Study
We (I) hereby authorize AGAPE and its employees and agents to release our fostre parent home study for the purpose of pursuing children who are available for adoption, to the following agencies and contract persons:
- Omni Inc
- Department of Children's Services
Name (Resource Parent 1):
Date of Birth (Resource Parent 1):

MonthDayYear
Date
Name (Resource Parent 2):
Date of Birth (Resource Parent 2):

MonthDayYear
Date
This Authorization will expire on the following date or upon the occurrence of the following event:
- We (I) understand that we (I) may revoke this Authorization at any time in writing prior to the expiration date or event, but that my revocation will not have any effect on the actions taken by the above-named social services agency or its employees or agents before they receive my revocation. Should I desire to revoke this Authorization, I must send written notice to the above-named social services agency by fax, email, or regular mail.
- We (I understand that our (my) records may be subject to disclosure by the recipient and may no longer be protected by federal privacy regulations.
Signature (Resource Parent 1):

Clear
Date:

MonthDayYear
Date
Signature (Resource Parent 2:

Clear
Date:

MonthDayYear
Date
Should be Empty: