I,, give permission for you to receive and release

any and all information requested below to the State of New Mexico Children, Youth and Families Department.

FBI CLEARANCE

ALL POLICE RECORDS

CRIMINAL RECORD AND CPS CHECKS FROM OTHER STATES

MEDICAL RECORDS AND INFORMATION

COUNSELING AND PSYCHOLOGICAL REPORTS

PREVIOUS HOME STUDY

SCHOOL REPORTS

PERSONAL REFERENCES

OTHER:

THE ABOVE INFORMATION WILL BE USED TO ASSESS MY APPLICATION FOR FOSTER CARE LICENSURE WITH THE NEW MEXICO CHILDREN, YOUTH AND FAMILIES DEPARTMENT

SIGNATURE: PRINTED NAME: ADDRESS: CITY: STATE: ZIP CODE: PHONE:

DATE:

SUBSCRIBED AND SWORN BEFORE ME THIS DAY OF 20 NOTARY PUBLIC

(seal) MY COMMISSION EXPIRES RELEASE OF INFORMATION

FORM