An Application Packet Page 9
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14Parent Responsibility Agreement
Parent Self-Declaration of Compliance
Case Name
Case Number
:
:
Are you complying with the requirement that you must not use, sell, or possess
marijuana or a controlled substance, or abuse alcohol?
Yes
No
If no, and you are in a treatment program, give details:
Did each child/children in your family younger than 18 years of age attend school
regularly, meeting school attendance requirements, in the last six months?
Yes
No
If no, please explain:
Parent Signature
Date
Parent Signature
Date
Form 2042A
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