(Agency/Parent/Legal Guardian):____________________________________________
does hereby agree that (Young Woman):______________________________________
for whom it has custody, shall be placed at the The Perry Center, 2355 Meadow Ridge Parkway, West Fargo, North Dakota, who shall stand in loco parentis to provide care, maintenance,
and guidance while this agreement remains in effect. However, legal custody of the young
woman shall remain with the undersigned agency, parent, or legal guardian. This agreement
shall be in effect until ___________ or until it is terminated as stipulated in this agreement. Both
parties involved agree to the following terms of placement:
PERRY CENTER:
A. The Perry Center shall provide care, maintenance, protection, and
guidance for the young woman according to her best interest which is decided upon by staff
at the Perry Center in consultation with the Placing Party.
B. The Perry Center shall cooperate with the Placing Party in seeing
that the young woman receives routine medical/dental care and treatment and shall act
immediately in medical/dental emergencies, notifying the Placing Party as soon as possible
in emergency situations and obtaining permission for planned special medical/dental care
and expenses.
C. The Perry Center shall confer with the Placing Party regarding the
young woman's development, activities, and problems while she is in our care, and provide
written progress reports as requested.
D. The Perry Center shall discharge the young woman at the time agreed, and give the Placing Party two weeks notice if we believe it is in her best interest to be
discharged prior to the agreed upon time.
E. The young woman shall be under the care of a licensed physician for the
duration of her pregnancy and for at least six weeks post-partum or until she leaves
the Perry Center.
F. Each young woman shall attend childbirth classes.
G. A support person shall accompany the young woman to the hospital
and remain with her until the birth of her baby.
H. All infants born to the woman while she is our client and until the
time of the infant's discharge from the hospital shall be under the care of a licensed
physician.
I. Each young woman will have a counselor assigned to her immediately upon
admission.
J. Each young woman will have a "support person / Big Sister"
assigned to her as soon as possible after admission.
K. Counseling will be available to the alleged father of the unborn child
and to the young woman's parents.
L. The young woman will receive counseling to assist her in arriving at
a suitable plan for herself and her child.
M. The young woman will be expected to participate in group discussions
and counseling.
N. The Perry Center will provide leisure time activities for the
benefit of the young woman. Some of the activities may include volleyball, bike riding,
"family" outings, board games, puzzles, playing cards, and crafts.
PLACING PARTY:
A. The Placing Party gives The Perry Center permission to authorize
necessary medical and dental care and consent to such emergency medical and surgical
treatment and/or hospitalization where the placing agency parents, or legal guardian
cannot be contacted prior to such emergency medical, dental, or surgical treatment.
B. The Placing Party shall bear the expenses of medical and dental care including
prescriptions (if insurance or medical assistance does not cover the cost).
C. The Placing Party shall give two weeks written notice prior to permanent removal of
the young woman from The Perry Center, except when the facility agrees to a shorter
notification.
D. The Placing Party shall continue to carry out their legal
responsibility for the young woman by visiting her at least every two months.
E. The Placing Party shall agree to accept the responsibility of
keeping The Perry Center informed of any change in address, employment, marital status, or
any major change in health.
F. The staff at the Perry Center is absolved from any and all liability
which may be incurred during its care of the young woman during her stay (except in the
case of reportable abuse or neglect).
VISITS:
A. Plans for visits with or by the Placing Party or friends shall be
according to the Visitation policies.
B. As responsible parents or guardians, the Placing Party will abide by the rules and
procedures in the matter of visiting the young woman and will cooperate directly with The
Perry Center staff in planning for the young woman's needs.
FINANCES:
A. We agree to pay the following rent: $_______per______________.
B. We agree to pay all medical expenses as outlined above.
| Parent/Guardian Signature:_____________________________ |
Date:_________ |
| Parent/Guardian Signature:_____________________________ |
Date:_________ |
| Address:__________________________________________ |
|
| Resident Signature:__________________________________ |
Date:_________ |
| Staff Signature:_____________________________________ |
Date:_________ |