(c) Written consent is required by the child’s parent or the agency having custody of the child, if applicable, and the child if the child is 14 years of age or older to disclose information from the child’s record and must include:
- (1) Date and nature of request for information.
- (2) Name of the person, agency or organization to whom disclosure is made.
- (3) Type of information disclosed.
- (4) Dated signature of the child’s parent, or the agency having legal custody of the child and the child if the child is 14 years of age or older.
- (5) Dated signature of a witness.
- (6) Expiration date of consent form.
- (7) Statement of the rights of the parent or agency having custody of the child and the child to revoke the consent each has given.