Step One Regional Consultation Program
6 Fort St. Quincy MA 02169
Tel: 617-774-1040 Fax: 617-847-0915
FAMILY RIGHTS AND RESPONSIBILITIES
I, the undersigned, hereby acknowledge that I will be responsible for selecting
a provider, from an agency or a family member/friend, to provide respite services
for my child. By using a family member or friend I acknowledge that this individual
will not go through a criminal records background check. I also affirm that
I have been strongly encouraged to have the family member/friend to be trained
in CPR and first aid. I understand that the Regional Consultation Program will
pay for CPR and first aid training for family members/friends serving as respite
providers. I acknowledge that information provided on the Respite Funding Request
Form will be reviewed by a regional team to determine eligibility for respite
funding. The regional team will be made up of staff from the Regional Consultation
Program, the Department of Public Health and Family TIES.
In addition, I acknowledge that I am solely responsible for arranging and approving the services and who provides them. I agree to provide the individual provider or agency with all necessary information to assist with the provision of services to my child in the safest and most competent manner possible.
Having read and understood the above, I expressly and voluntarily consent to take full responsibility for the individual or agency and for the services provided through the respite program. I further release the Department of Public Health, the Regional Consultation Program and South Shore Mental Health from any liability associated with the respite services provided and agree to indemnify both the Department of Public Health, the Regional Consultation Program and the South Shore Mental Health against any action arising out of the respite services provided.
Parent/Guardian Signature: ____________________________________
Today’s Date: _________________________
Relationship to Child: _________________________
Child’s Name: ____________________________________
Child’s DOB: _________________________
***THIS DOCUMENT MUST BE INCLUDED WITH THE RESPITE FUNDING REQUEST FORM AND SUBMITTED TO THE RCP AT THE TIME OF THE REQUEST.***