Please review and sign.

1. POLICY & PROCEDURE VERIFICATION FORM
 The Client agrees that by signing this form they are acknowledging receipt of Agency Policies and
Procedures as applied to the Foster Care Program.
 The Client agrees they have read, reviewed, and discussed the policies with The Agency.
 The Client understands and agrees to comply with the provisions set forth in each of these policies.
 The Client understands and agrees to comply with each of the procedures set forth for policies.
 The Client understands that the issuance of these Policies and Procedures does not imply nor
constitute a contract of placement, guarantee of continued placement, nor placement for a definite
period of time.
 The Client understands that the Policies and Procedures are written to comply with state minimum
standards for a Child Placing Agency (CPA). Furthermore, The Client understands that minimum
standards are considered Laws of the State of Texas.
If at any time I do not believe I can comply with these laws and/or continue to comply with these
laws as written and amended from time to time, I will contact my Case Manager and/or the Program
Director of The Agency immediately.
THE CLIENT DATE
THE CLIENT DATE
THE AGENCY DATE
Latest Revision: 06/01/09 Page 1 of 1 file: CPA Policies/Forms/Parent Files/Policy & Procedures
Verification