Consent to Release Confidential Information

Expectant Parent Full Name *

Expectant Parent Date of Birth * +

Do hereby consent and authorize the Texas Adoption Center to release any information pertaining to me and my adoption plan to the persons indicated below, and I also authorize Texas Adoption Center to release information/documentation regarding my adoption record to:

Full Name:

Relationship:

Full Name:

Relationship:

This authorization is good from the date of my signature until one year after my child’s birth.

I understand that I may revoke this consent at any time by notifying Texas Adoption Center in writing, except to the extent that action has been taken in reliance on my consent. A

photocopy of this authorization is to be considered as valid as the original document.

Expectant Parent Signature: *

clear

Date: +

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