New Gateways Policy Acknowledgment Form
Acknowledge receipt and understanding of the Illness Policy and Protection from Caregiver Abuse Policy.
Acknowledgment Statement
I acknowledge that I have received, reviewed, and understand the following New Gateways policies:
• Illness Policy
• Protection from Caregiver Abuse Policy
I understand the expectations, guidelines, and procedures outlined in these policies. I have had the opportunity to ask questions and receive clarification as needed.
I agree to comply with these policies and understand that they are in place to promote a safe and supportive environment for all persons served.
Individual / Person Served Information
Name
*
Signature
*
Date
*
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Month
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Day
Year
Date
Family Member / Guardian Information (if applicable)
Name
Relationship
Signature
Date
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Month
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Day
Year
Date
Acknowledge
Acknowledge
Should be Empty: