New Haven Youth and Family Services

Acknowledgement of Receipt of Processes and Procedures


Youth Name: ______________________________________

Date of Birth: ______________________________________


The following set of New Haven processes & procedures were provided to me or offered to me at the time of admission:

X      Contact Information

X      Placement Agreement

X      New Haven Code of Conduct

X      Personal Property Policy, including Cash Resources

X      Dress Code, Contraband, and Search & Seizure Policies

X      Emergency Intervention Plan

X      Phone Use & Visits

X      AWOL (Runaway) Plan & Protocol

X     Home Pass Policy & Drop-off Locations

X     California Department of Education Universal Complaint Procedure

X     Resident Complaint Procedure

X     Non-Discrimination and Harassment Statement


By signing below, I acknowledge that the above listed Processes & Procedures, have been explained to me thoroughly and in detail.


____________________________________              __________

Signature of Parent, Guardian, or Representative                    Date


____________________________________              __________

Signature of Youth                                                                           Date


____________________________________              __________

Signature of New Haven Representative                                    Date