OCYF Bulletin 3140-03-01
11
SAMPLE CONTRACT A AGENCY NAME INDEPENDENT LIVING PROGRAM YOUTH:
DATE:
YOUTH NAME Responsibilities:
1. Maintain fulltime employment at (PLACE OF EMPLOYMENT) and provide IL staff person with check stubs to verify hours and income. 2. Sign up for a GED program (LOCATION OR NAME OF AGENCY) by DATE. 3. Attend 90% of GED classes once enrolled. 4. Develop and follow personal budget and savings plan with IL staff person or other assigned staff person. 5. Cooperate with drug screenings every two weeks. AGENCY NAME will conduct tests or take (YOUTH NAME) to (NAME OF LAB) for tests. Tests may initially be positive for marijuana. By (DATE), tests should be clean. (Use as appropriate) 6. Meet with counselor at least two times a week or as necessary. (As appropriate or by need) 7. Cooperate with 5 to 7 random checks on apartment per week. (As appropriate or by need) 8. Only allow visitors until 11:00PM and no more then two at a given time. (example) 9. Meet with therapist (NAME) one time per week. (example) 10. Sleep on site at his/her apartment unless permitted to be elsewhere by AGENCY NAME and COUNTY AGENCY. 11. Follow all local, state, and federal laws.
OCYF Bulletin 3140-03-01
12
Sample contract A Agency/Provider Responsibilities:
1. Pay rent and security deposit through December 2002. 2. Provide $35.00 per week in food coupons. 3. Pay all reasonable utility bills. Maximum amount will be jointly determined by NAME and counselor. 4. Provide individual counseling and therapy. 5. Provide a monthly-unlimited ride bus pass. 6. All payments are based on youth’s name following his portion of the contract.
County Responsibilities: 1. Monitor youth’s compliance with this contract. 2. Should youth fail to follow through with the contract, remove him/her from the program within two weeks.
________________________________
Signature of youth
_____________
date
______________________________________ Signature of agency/provider staff
________________ date
______________________________________ Signature of county worker
_________________ date