Form Dss-5108 - Dss/student Contractual Agreement For Continuing Residential Support - Nc Family Support And Child Welfare Services

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DSS/Student Contractual Agreement
For Continuing Residential Support
For Persons Ages Eighteen to Twenty one Years
For Emancipated Persons Under the Age of Eighteen Years
I, _____________________________ hereby request to remain in the placement
responsibility of the _________________ County Department of Social Services. I
understand that my signature on this agreement gives the __________________ County
Department of Social Services the authority to continue my placement in foster care and
to provide foster care services and other services for which I am eligible.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
I understand that I must remain enrolled in a full-time program of academic or vocational
training, or accepted for full-time enrollment for the next term in an academic or
vocational program in order for foster care assistance payments to be paid on my behalf.
I also understand that my eligibility for LINKS services or transitional assistance is not
dependent on my participation in this contract.
I understand that both the Department of Social Services and I have the right to rescind
this agreement. I agree to discuss any problems arising from the placement with the
social worker, and am committed to handling my responsibility in working through any
problems that are within my control. I agree to notify the agency and placement provider
in advance if I decide to leave school, the vocational program, or foster care. I also
understand that this agreement will automatically be ended on my twenty-first birthday.
Requested by:____________________________ Date _______________________
Student
Accepted by: ____________________________
Date _______________________
Social Worker
Approved by: ____________________________
Date _______________________
Agency Director
DSS-5108
Family Support and Child Welfare Services

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