Acknowledgement and Receipt of Policies and Procedures
Please complete this form to acknowledge receipt of policies and procedures for Integrity Colorado LLC’s Day Program. For questions, contact Integrity Colorado LLC | Phone: (720) 219-0428 | Address: 10500 E. Girard Ave,. Suite 131 Denver, CO 80231
Name
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Date of Birth (DOB)
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of person who has been provided with a copy of the policies and procedures
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Parent/Provider Name
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First Name
Last Name
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Provider Signature
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Participant’s Name
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First Name
Last Name
Participant’s Signature
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[Name] has been provided with a copy of the policies and procedures for Day Program at Integrity Colorado LLC. By signing below, I am acknowledging that I have received, read, and understand the following policies and procedures:
1. Dispute Resolution Process
2. Grievance and Complaint Process
3. M.A.N.E – Mistreatment, Abuse, Neglect and Exploitation Policy and Procedure
4. Rights of the Person Receiving Services
I acknowledge that I have received, read, and understand the above policies and procedures.
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I acknowledge that I have received, read, and understand the above policies and procedures.
Submit Acknowledgement
Submit Acknowledgement
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