Acknowledgement of Policy

Dear Parent/Guardian or Referring Agency:

It is required that the Bay County Juvenile Home provide each parent/guardian and referring agency with a copy of specific policies listed below. It is requested that initial and sign below indicating that you have received each policy. All policies are available on the Juvenile Home website under “Parent Packet”

I have reviewed the following policies on the Bay County Juvenile Home website

Please initial each:
Program Statement
Grievance Policy
Religion Policy
Intervention Standards
Seclusion Policy
Mechanical Restraint Policy
Emergency Restraint Policy
Health Status Assessment
Your signature verifies that you were able to access the polices online and review them. You understand that if you have questions or concerns you may speak with a Supervisor or the Director.

For further questions or concerns I may contact:
Supervisor Joe Beauchamp or Director Juli Reynolds
Signature: *

Clear
Date: *

Month Day Year
Date
Print name: *
Youth's Name:
Relationship to youth:
Email address to receive copy of this form *
example@example.com
Representing Court/Agency:
Attach this form into the Youth’s file
Should be Empty: