STUDENT RELEASE FORM
To document the release of a dependent child into the custody of an authorized agent
of the Florida Department of Children and Family Services or law enforcement officer
I am removing ________________________________ __________________, from
(Student’s Name)
(Date of Birth)
_______________________________, and taking such student into protective custody
(School)
pursuant to Section 39.401, Florida Statutes.
I have reasonable grounds to believe (check one):
____ The student has been abandoned, abused, or neglected; is suffering from illness or
injury; or is in immediate danger from his or her surroundings and removal is necessary to
protect the student.
Or
____ The custodian of the student under protective supervision has violated in a material way
a condition of the placement imposed by the court.
The agency that I represent assumes full responsibility for the student and for notifying the
student’s parent, guardian, or legal custodian that the student has been taken into protective
custody.
Signature of Agent or Officer: ______________________________________
Name of Agent or Officer: _________________________________________
Agency/Department _____________________________________________
Date: _________________________ Time: ___________________________
Witnessed by:
_________________________________
Signature of Principal or Designee
Name: ___________________________
Position: _________________________
SSE0001 Rev.05/13