! District Court ! Denver Juvenile Court _________________________________________ County, Colorado Court Address: IN THE MATTER OF THE ADOPTION OF: AND CONCERNING: , Petitioner Attorney or Party Without Attorney (Name and Address): COURT USE ONLY Case Number: Phone Number: FAX Number: E-mail: Atty. Reg.#: Division CONSENT RELEASE OR REFUSAL TO CONTACT Courtroom I, __________________________________________________________________________, CONSENT TO CONTACT with my _________________________________________________________________________________(relationship). My legal name is: My legal birth name was: I agree to the following form of contact: Date of Birth: _____________________ _______ ! ! exchange of correspondence personal meeting ! ! telephone call other (specify) _________________________________________ I state that my consent is voluntary and informed, and I release the confidential intermediary, the training organization, the Court and any agency from any liability resulting from this contact. ___________________________________________________ ___________________________________________ Confidential Intermediary Date Signed Date _________________________________________________________________________________________________________________________________ Address of Signatory I, _______________________________________________________________________________, REFUSE CONTACT with my __________________________________________________________________________________(relationship). My current legal name is: My legal birth name was: Date of Birth: ____________________ I acknowledge receipt of information about the Colorado Voluntary Adoption Registry for my use in the event I should ever desire to have contact with this individual. It is my present desire that the records remain sealed and my anonymity be preserved. _____________________________________________ ___________________________________________ Confidential Intermediary Date Signed Date _________________________________________________________________________________________________________________________________ Address of Signatory I certify that a signed copy of this Consent Release or Refusal to Contact was received in the __________________Court, ________________County, Colorado. _____________________________________________ Date JDF 346 R9/00 CONSENT RELEASE OR REFUSAL TO CONTACT 2001 � American LegalNet, Inc. ___________________________________________ Signature of Clerk