Connected Youth Initiative

Nebraska Older Youth Support Services Fund

*REQUIRED
*REQUIRED
*REQUIRED
*REQUIRED
*REQUIRED
*REQUIRED
*REQUIRED
*REQUIRED

Read before signing:

I understand and authorize the Nebraska Department for Children and Families to verify my former legal custody status and associated dates with the State Child Welfare System or Tribal Authority.

I understand that the information which I have authorized to be disclosed will be used for the purpose of determining my eligibility. I acknowledge that it is my responsibility to be aware of any rights of confidentiality which I may have regarding the information which I am releasing and that by signing this consent I am waiving my rights, if any, to confidentiality for purposes which I have approved.

If I have authorized the release of information to a person or agency providing independent living or foster care services under contract with my associated State Child Welfare System or Tribal Authority. I have also authorized release of the information to any person or agency providing that service under sub-contract.

This consent may be revoked in writing at any time prior to any action which has been taken in reliance upon it.


This authorization will expire on 10-10-2022.

*REQUIRED
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