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ROI (Hamilton County Juvenile Court)

Release of Information

Name of Participant(Required)

Release of Information (ROI) Consent

I understand my student’s story and/or my story is ours to share. I understand Back2Back Cincinnati will hold our information confidential unless necessary by law. I realize Back2Back Cincinnati can better serve my student and/or our family when they communicate to other individuals working with my student and/or our family. I give permission for Back2Back Cincinnati to give and receive information in regards to my student(s) and/or myself from Hamilton County Juvenile Detention Center (20/20), Hamilton County Juvenile Probation, Hamilton County Public Defender’s Office, Hamilton County Diversion Court Programs and Hamilton Prosecutor’s Office.
Name of Consenting Guardian or Student (if over 18)(Required)
Submitting your name below as a digital signature, you are acknowledging any release of information and understand that the permission can be revoked at any time by contacting Back2Back Cincinnati in written format either in email or letter.
Provide the date of consent and submission of this form.
MM slash DD slash YYYY