Form Dss-1789 - Voluntary Placement Agreement Page 2
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2The child’s special health, educational or emotional needs are:
Parent/Guardian asking for placement is:
Name______________________ Telephone number_____________________
Address _________________________________________________________ Place
of Employment __________________________Telephone ___________
Child’s other Parent(s): Name
____________________________Telephone________________ Address
__________________________________________________ Place of
Employment________________________________________
Name ____________________________Telephone________________
Address __________________________________________________ Place
of Employment________________________________________
By signing this agreement I acknowledge that the agreement has been discussed thoroughly
with me. I agree to this placement with a full understanding of the issues as outlined above
and those covered in the Service and Visitation Agreements. The DSS agrees to provide
placement and services to the family and child as outlined above and in the Case Plan–
Service Agreement.
The undersigned parties to this VPA also hereby acknowledge and stipulate that proof of their
agreement may be evinced by a copy of this document signed by the parties, including one that
has been produced by a facsimile machine.
Parent/Guardian_____________________________________Date________________
Parent/Guardian_____________________________________Date________________
Social Worker_______________________________________Date________________
Director of DSS ______________________________________Date_______________
Revocation Process
Parent must notify the County DSS in writing that they wish to revoke this agreement.
Once notified in writing, the county must within twenty-four hours of notification either return the
child to the parent/guardian or obtain custody of the child through Juvenile court.
dss-1789 rev 10/2010
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