Form Soc 155b - Mutual Agreement For 18 Year Olds

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
MUTUAL AGREEMENT FOR 18 YEAR OLDS
CASE NAME
BIRTH DATE
CASE NUMBER
I request that the _________________________ County Welfare Department place me _______________________________________
(NAME)
in a licensed/certified foster home or childrens’ institution. My reason for the request is _________________________________________
_____________________________________________________________________________________________________________
I expect to remain in Foster Care until completion of my education/training by age 19.
Agency Service is to include:
1.
Arrangement for my care in a licensed certified Foster Care Facility.
2.
Selection of a home with my participation.
3.
Supervision of me while in Foster Care.
4.
Provision of social services for me.
5.
Arrangements for my medical care.
6.
Assistance in planning for my leaving foster care.
7.
Provision of a grievance procedure.
Recognizing my responsibility for participating in the Foster Care plan, I agree to:
1.
Assist the welfare department in determining my financial need and eligibility while in foster care.
2.
Keep the agency informed of my progress with my education/training program.
3.
Discuss with the agency placement problems.
4.
Give reasonable notice to the placement worker if I plan to move, but I retain the right to withdraw my consent to
placement at any time.
The undersigned agrees to foster care placement and supervision by the ______________________________________ County Welfare
Department.
SIGNATURE OF FOSTER CARE CHILD
CHILD PLACEMENT WORKER
ADDRESS
ADDRESS
HOME PHONE
OFFICE PHONE
ALTERNATE
DATE
Required Form
No Substitute Permitted
SOC 155B (3/00)

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