RFP10858_Exhibit 5_ParentResponsibleAffidavit.pdf
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- Solicitation number
- RFP-10319
- Issued by
- Broward County, Graceville City, Florida
About this file
This document is an Exhibit 5 Parent/Responsible Adult Release Affidavit related to a Request for Proposal (RFP) issued by the Florida Department of Juvenile Justice (DJJ) and the Office of Probation and Community Intervention for detention screening and intake services at the Broward Juvenile Assessment Center (JAC) located in Broward County, Florida. The Respondent shall provide these services twenty-four (24) hours per day, seven (7) days a week.
The affidavit requires the parent, guardian, or responsible adult to provide their personal information, including name, relationship to the child, address, phone number, and date of birth, as well as the child's name and date of birth. The affidavit must be signed by the parent, guardian, or responsible adult and witnessed.
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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 .