Form Soc 155 - Voluntary Placement Agreement - Placement Request
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
One copy to:
Parents or Guardian
VOLUNTARY PLACEMENT AGREEMENT —
Agency File
PLACEMENT REQUEST
Foster Care Facility File
I request that:
The child welfare department of__________________________________________________________________County
The______________________________________________________________________________Adoption Agency or
The California Department of Social Services (CDSS) acting as an adoption agency
place______________________________________________________________________________ in a foster care facility.
(CHILD’S NAME)
The reason for my request is____________________________________________________________________________.
CHILD’S LEGAL STATUS
The child is under the age of 18, and my legal responsibility as a parent or guardian ...................................
YES
NO
By signing this agreement
•
I give custody and control of my child to the county welfare department, the public or private adoption agency specified
above, or the CDSS acting as an adoption agency to arrange for my child’s care, supervision, custody, conduct,
maintenance and support, including medical care.
•
I authorize the county welfare department, the public or private adoption agency specified above, or the CDSS acting as an
adoption agency and the home or facility where my child will be staying to give legal consent for medical care, school
attendance and the other services my child may need. But I do not authorize the home or facility or the county welfare
department, the public or private adoption agency specified above, or to the CDSS acting as an adoption agency to give
consent for___________________________________.
•
I understand that voluntary placement is usually limited to six months, but sometimes six more months can be approved for
a total period not to exceed twelve months.
•
I understand that my child may be eligible for benefits under the foster care program.
•
I understand that the voluntary placement laws are in California Welfare and Institutions Code Section 11400(n) and
Sections 16507.3 through 16507.6 and that I can get help from the county if I want a copy.
•
I understand that I can withdraw this request or terminate this placement agreement at any time.
PARENT OR GUARDIAN AGREES TO
1. Give the county welfare department, the public or private adoption agency specified above, or the CDSS acting as an
adoption agency the information they need to decide how much I will pay (if anything) for my child’s care.
2. Tell the county welfare department, the public or private adoption agency specified above, or the CDSS acting as an
adoption agency if my address or phone number changes.
3. Visit my child when scheduled with the home or facility where my child will be staying.
4. Allow the county welfare department, the adoption agency specified above, or the CDSS acting as an adoption agency to
move my child to another home or facility if necessary.
5. Allow my child to participate in the activities planned by the home or facility, including trips within California.
6. Do what my child’s service plan says I should do.
7. Talk to the county welfare department, the adoption agency specified above, or the CDSS acting as an adoption agency
about any problems my child or I might have with the home or facility where my child will be staying.
8. Tell the county welfare department, the public or private adoption agency specified above, or the CDSS acting as an
adoption agency before I move my child out of the home or facility
THE UNDERSIGNED HAS CUSTODY AND CONTROL OF THE CHILD.
CHILD PLACEMENT WORKER
SIGNATURE OF PARENT OR GUARDIAN
ADDRESS
ADDRESS
HOME PHONE
ALTERNATE PHONE
DATE
OFFICE PHONE
PLEASE READ IMPORTANT INFORMATION ON THE REVERSE SIDE
SOC 155 (5/99) REQUIRED FORM — NO SUBSTITUTE PERMITTED
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