MISSOURI CHILDREN’S DIVISION

RAISE THE FUTURE

CONSENT TO RELEASE IDENTIFYING INFORMATION FOR

ADOPTION PURPOSES

Date:
In The Interest of:
Case No.:
Application to Release Identifying Information for Adoption Purposes
Pursuant to Section 211.321, RSMo., the Missouri Department of Social Services,
Children’s Division,	County Office, requests permission to use
and release photographs, biographical information and other identifying information
regarding the child,	, to Raise the Future.
This information will be used for state and nationwide media recruitment purposes to
pursue a permanent home for the child,	, over
whom the court has jurisdiction.
Consent to Release Identifying Information for Adoption Purposes
Consent is hereby given to the Missouri Department of Social Services, Children’s
Division,	County Office, to use and release
photographs, biographical information and other identifying information regarding the
child,	to Raise the Future for the purpose
of pursuing a permanent home for the child.
It further Ordered that the Clerk of the Court certify two (2) copies hereof to the
Children’s Division	County Office, one (1) copy
hereof to	GAL, and one (1) copy
hereof to	, attorney.
So ordered,
(Date)	Circuit Judge
Please note any restrictions on use in specified geographic areas.