Form Soc 163 - Voluntary Re-Entry Agreement For Extended Foster Care Page 2
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
5.
If I am voluntarily living with my previously juvenile court appointed nonrelated legal guardian:
I agree to voluntarily live with my previously juvenile court appointed nonrelated legal guardian and
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understand that the county case worker will be supervising my case and I agree to participate in
updating my six month TILP; AND
I understand that if I don’t participate in one of the five eligibility activities as described in my TILP, the
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county agency may stop payments and close my case. I understand that I will receive written notices
of action (NOAs), and I can appeal these actions.
___ I agree to live in an appropriate approved or licensed foster care placement and agree to:
1.
Tell my county case worker about any problems with my placement and work with my case worker to
find solutions.
2.
Make sure my county case worker always has a way to contact me, and tell my case worker within one
week if my phone number, mailing address, or other contact information changes.
3.
Tell my county case worker within 24 hours after I complete a planned move to a new placement, or move
out of my current placement for any other reason.
4.
I understand that if I leave my foster care placement, the foster care funding will be stopped until I am
residing in another approved placement.
___ I understand that if I leave foster care, I can petition the juvenile court for re-entry to foster care and
receive assistance from the county agency with filing the petition if I am under the age limit.
___ I understand that the following conditions would make me ineligible to remain in foster care:
Getting married
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Joining the military
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Incarceration (sentenced to confinement)
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___ The county agency agrees to:
1.
Help me develop and achieve my goals for stable and permanent housing and independent living, as
described in my TILP.
2.
Review the goals in my TILP and update them at least every six months.
3.
Help me find an appropriate approved or licensed placement (foster home, relative’s home, foster family
(
agency home, short-term residential therapeutic program
STRTP) or group home, transitional housing
program, or supervised independent living placement or remain with my nonrelated legal guardian).
4.
Help me stay eligible for extended foster care by responding to any problems I have reported and help me
find services and supports to meet my needs and maintain eligibility.
5.
Help me develop a Shared Living Agreement, as needed, and help resolve any problems that arise with
my placement.
6.
Ensure that I have MediCal or other health insurance, and help me get medical, dental, and/or mental
health care as needed.
7.
Tell me about any changes to my foster care benefits and give me information about the procedure to
appeal a decision to either cut off or reduce my benefits.
8.
Make sure I have contact information for my attorney, and information about upcoming juvenile court
hearings, and how to participate in these hearings as applicable.
The undersigned agrees to foster care placement and supervision by the _________________________ County Agency.
Print Nonminor’s Name:
Case Worker’s Name:
Supervisor’s Name:
Nonminor’s Signature:
Case Worker’s Signature:
Supervisor’s Phone Number:
Nonminor’s Contact Phone Number:
Case Worker’s Phone Number:
Tribal Authority Name:
Date:
Date:
Tribal Authority Phone Number:
Are You Registered to Vote? Access to voter information and registration can be found at the following links:
Secretary of State Voter Registration
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Secretary of State Voter Information Contact
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Secretary of State Voter Hotline: (800) 345-VOTE (8683)
SOC 163 (7/17) (NO SUBSTITUTES PERMITTED)
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