CCTHITA TRIBAL COURT
320 West Willoughby Ave. Suite 300
Juneau, Alaska 99801
Phone: Toll- Free 1-(800) 344-1432
(907) 586-1432
In the Central Council Tlingit and Haida
Indian Tribes of Alaska Tribal Court
Juneau, Alaska
CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION
By signing this form, you are authorizing Tribal Court to release otherwise confidential information to one or more people
whom you designate. Please read carefully. We will gladly answer any questions.
I authorize Tlingit & Haida Tribal Court to: (Check all that pertain)
Discuss and disclose otherwise confidential information pertaining to my child custody case.
Other: ___________________________________________________________________________
I authorize the release of the information specified above to:
____________________________________________________________________________________________________
________________________________________________________________________________
This information is released for the following purpose(s):
To coordinate child custody management services.
Other: ___________________________________________________________________________
If you have authorized us to discuss confidential information, specify the period during which we may communicate with the
person(s) listed above, by checking the appropriate box below:
I authorize ongoing communication unless I revoke this consent.
I authorize communication only until __________________________________ (specify date).
Other restrictions or limitations on information to be released (specify):
_____________________________________________________________________________
No other limitations
I understand that I do not have to agree to release confidential information, and that I may withdraw this consent at any time
except insofar as action has already been taken in reliance thereupon. A facsimile of this form will be regarded as valid as the
original. I understand that I am authorizing the release of my confidential information held by Tlingit & Haida Tribal Court for purposes
of case management services.
I understand that if I am protected by a restraining order or I have reason to believe I may be emotionally or physically
harmed, I have a right to request that information on my whereabouts be withheld from anyone including other parties to my
Court case. I hereby release the Tlingit and Haida Indian Tribes and the Tlingit and Haida Tribal Court and its designee
named above from liability for the release of any information authorized under this agreement.
As evidenced by my signature below, I hereby authorize disclosure of records to the person(s) or agency(s) specified above.
Signature: ______________________________________________ Date: ______________________
Name (printed): __________________________________________
