RFP10858_Exhibit 5_ParentResponsibleAffidavit.pdf
PDF 115 KB Posted
- Solicitation number
- RFP-10319
- Issued by
- Broward County, Graceville City, Florida
About this file
This document is an Affidavit for the Parent/Responsible Adult Release from the Department of Juvenile Justice Juvenile Assessment Center. The Affidavit requires the parent, guardian, or responsible adult to provide their name, relationship to the child, the child's name and date of birth, and contact information including home phone, cellular phone, and pager. The parent, guardian, or responsible adult must attest that the provided information is true and factual, and the Affidavit must be witnessed and signed.
The Affidavit does not contain any information about pricing terms, set asides, incumbents, funding requirements or sources, or contract details. This document appears to be a standard form required by the Department of Juvenile Justice Juvenile Assessment Center to release a child to their parent, guardian, or responsible adult.
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Text version
EXHIBIT 5
Department of Juvenile Justice Juvenile Assessment Center
Parent/Responsible Adult Release Affidavit
I, ____________________________________________________ Name attest that I am the _____________________________________of Parent/Guardian/Responsible Adult
________________________________________ whose address is Child’s Name
__________________________________________________, and Address date of birth is ________________________. I may be reached at
DOB
Home Phone Cellular Phone and/ or _________________________.
Pager
Parents Information
Date of Birth ___________________________
Type of Identification provided: ______________________________
I attest that the above information is true and factual.
Signature of Parent/Guardian/Responsible Adult Date
Witness
Reviewed By:
Intake Screener Date
Lead Screener Date
File details come from the government source that posted it. Updated .