Child Welfare

V-9 Extended Care Policy

graphic of a person at a crossroads

DEPARTMENT OF HEALTH AND HUMAN SERVICES
APPLICATION AND AGREEMENT OF RESPONSIBILITY FOR CONTINUED CARE
VOLUNTARY EXTENDED CARE AGREEMENT (V9)

DATE: ____________________

Part I

I hereby make application to the Department of Health and Human Services for continued care and support beyond my 18th birthday.

Name: ____________________ Birthdate: ______________________

Address: ____________________________________________________

Part II

The terms of this agreement are as follows:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

I understand that this contract will be terminated if I marry or do not follow through with the terms of this agreement.

I understand that either the Department of Health and Human Services or I may terminate this voluntary agreement by a ten day notice in writing. If this agreement is terminated, I understand that I have a 90 day period within which to renegotiate this agreement under terms that are mutually agreed upon between myself and my caseworker. I also understand that I have the right to request a meeting with my caseworker and their supervisor to discuss any decision to terminate, or change the terms of my agreement.

I understand that the Department of Health and Human Services will not be financially responsible for any damages that I am responsible for, nor will the Department of Health and Human Services provide legal counsel for me if I am involved in a legal situation after the age of 18.

I understand that the Department of Health and Human Services will not be financially responsible for any contracts that I enter into after the age of 18.

Youth's Signature: ___________________________

Department of Health and Human Services Caseworker: ___________________________

Department of Health and Human Services Supervisor: ___________________________