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HomeMy WebLinkAboutC87-038 Echo Ranch - MurnighanAGREEMENT BETWEEN ECHO RANCH, INC AND WILLIAM MURNIGHAN and LINDA MURNIGHAN This agreement by and between Echo Ranch, Inc., a Colorado not-for- profit corporation by and through its Board of Directors (hereinafter Echo) and William Murnaghan and Linda Murnaghan (hereinafter Houseparents). WITNESSETH Whereas, Echo and the Houseparents desire to enter into an agreement to fully recognize the contributions of the Houseparents to Echo and to assure continuous harmonious performance of the affairs of Echo. Now therefore, Echo and the Houseparents, for the considerations hereinafter set forth, agree as follows: S 1.1 Employment Echo hereby hires William Murnighan and Linda Murnighan as Houseparents and William Murnighan and Linda Murnighan do hereby accept such position upon such terms and conditions hereinafter set forth and agrees to perform the duties required of them to the best of their ability. S 1.2 Term of Employment The terms of this agreement shall commence as of 16th day of February, 1987 and shall continue under this contract until 15th day of February, 1988, This contract may be extended by mutual written agreement of the parties. Upon expiration of this agreement, it shall be deemed extended on a month to month basis in the event no written extension is executed. Echo may terminate this agreement upon 30 days written notice and the Houseparents may terminate this Agreement upon 60 days written notice to the Board of Directors. Echo agrees to provide storage for personal property of the Houseparents for 30 days past the last day of work if it should terminate this contract on 30 days notice. Echo reserves the right to terminate this contract immediately and without notice for any cause that deems the houseparents unfit to continue their responsibilities. A determination of unfitness must be based on physical infirmity or acts or omissions which endager a child or inidicate a Cj; character trait that results in serious liability to Echo. Such a determination is made by a majority of the Echo Board of Directors. S 1.3 Compensation For all Service rendered by the Houseparents under this Agreement Echo shal l pay the Houseparents a monthly salary of $1000.00 payable on the 7th day of each calendar month for the preceding monthly period. The first 90 days of employment shall constitute a probationary period. At the end of such period, an Evaluation of job performance shall be conducted and an increase in salary shall be considered. For purposes of this contract and payroll, Linda Murnighan shall be the designated employee. S 1.4 Benef its The Houseparents shall also receive the following benefits: (a) Room and Board; (b) The Designated Employee shall accrue Sick Leave at a rate of 12 hours per month. (c) Houseparents shall receive 10 days of paid vacation leave per year. Vacation shall accrue monthly beginning on February 16, 1987. Houseparents shall be eligible for vacaction after 6 months of employment. Houseparents shall have two weekends as leave each month. (d) All time off the job must be coordinated with and approved by the Echo Executive Committee so that a substitute is available to be at the home. (e) The Houseparents shall participate in the following benefit plans, upon terms indicated in the respective pians themselves: (1) Medical Insurance which includes hospitalization and Major Medical coverage. (2) Term Life Insurance in an amount not less than $10,000 (3) Workmen's compentsation -2- (f) Houseparents may use their personal vehicles for accomplishing official Echo business. They will be reimbursed at a rate of $.20 per mile for such usage subject to the approval by the Executive Committee. S 1.5 Expenses The Houseparents are authorized to incur reasonable expenses on behalf of Echo including but not limited to, expenses for food, supplies, maintenance, and needs of the children placed at the Ranch. All cash expenditures over $100.00 shall be approved by the Echo Executive Committee prior to expenditure. Expenses under the amount may be paid out of petty cash or other funds and reimbursed by Echo upon approval of receipts turned in to the Treasurer. Houseparents may make expenditures over $100.00 but under any credit limit on charge accounts approved by the Board. S 2.1 Duties The Houseparents' duties shall include, but are not limited to, rendering professional services as described in the job description attached hereto as Attachment A and by this reference made a part hereof. Other duties of the Houseparents shall include tasks outlined as the responsibility of the Houseparents in the Admissions Policy and Criteria, the Medical Policy, the Discipline Policy, the description of Specialized Services, all of which are attached hereto as Attachment B and by this reference made a part hereof, and any other task which Echo may reasonably direct. The job description or any document in Attachment B may be amended by Echo from time to time and any such amendment which affects the duties of the houseparent will become effective hereunder upon notice of such amendment to the Houseparents. The Houseparents shall perform their duties hereunder in accordance with such standards of professional ethics and practice as may from time to time be applicable during the term of this agreement. Policies and Procedures for accomplishing the purposes of Echo shall be reviewed by Echo Board of Directors before implementation. S 2.2 Extent of Services Houseparents understand that William Murnighan is permitted to accept employment outside of their responsibilities to Echo. In the event of such employment, written notice shall be given to Echo. Linda Murnighan, as the designated employee, shall remain in the home on a full time basis for the duration of the contract. The Houseparents have the right to request a ISM change in the designated employee. Approval of such a request shall be considered on the basis of the effect a change would have on the residents of the home. S 3.1 Notice Any notice provided for herein shall be given in writing by registered or certified mail, return receipt requested, which shall be addressed as follows: ECHO: Housparents: Echo Ranch, Inc Murn i ghan PO Box 1567 c/o Echo Ranch Avon, Colorado 81620 PO Box Gypsum, Colorado S 3.2 Modifications and waiver No modification of this Agreement shall be valid unless such modification is in writing and signed by Echo and Houseparents. No waiver of any provision of this Agreement shall be valid unless in writing and signed by the person or party against whom charged. S 3.3 Applicable Laws This Agreement shall be subject to and governed by the laws of the State of Colorado. 5 3.5 Invalid Provision The invalidity or unenforceability of any particular provision of this agreement shall not affect the other provisions hereof, and this Agreement shall be construed as if such invalid or unenforceable provisions were omitted. S 3.6 Assignment This agreement shall be binding upon and inure to the benefit of Echo and the Houseparents and their respective heirs, legal representatives, executors, administrators, successors and assigns; provided however, that neither party may assign nor delegate any of its rights or obligations hereunder without first obtaining the written consent of the other party. -4- S 3.7 Arbitration Any controversy or claim arising out of or relating to this Agreement shall be settled by arbitration in accordance with the rules of the American Arbitration Association, one Arbitrator, and shall be enforceable in any court having competent jurisdiction. In Witness .,� hereof, the parties have hereunto set their hands and seals the day of Febg±tftmr7—, 1987. 11M 1C h Echo Ranch, Inc. e-cretary Houseparents William Murni Li da Murnighan -5- STATE OF COLORADO ) ss. County of Eagle ) The foregoing was acknowledged before me this 14 day of 1987, by William Murnighan and Linda Murnaghan. ilk k rq Witness my hand and official seal. My commission expires .= EXHI k JOLT DESCRIPTION: ECHO RANCH HOUSE PARENTS Job Responsibilities Responsibilities to Residents To provide 24 hour on-site live-in care for up to 10 adolescents. To participate in recording and evaluating the progress of the residents. To provide a healthy, constructive environment within the policies and procedures of the Echo Ranch Group Home . To provide transportation to school, house activities, appointments, and other situations as needed. To assist residents in preparing well-balanced meals. To provide a study hour for the residents. To attend all regularly scheduled group home resident therapy sessions and those sessions requested by Social Services. or Mental Health. To assist residents in maintaining the home and vehicles of Echo Ranch. To respond to emergencies or crises such as runaways, suicide, or extreme acting out -behavior according to group home policy. To admit and orient new admissions to the home according to group home policy. To admit and log all temporary care children into the home. To plan, coordinate, and participate in activites with and for the residents. To coordinate home visits and evaluate the child's behavior prior to departure and upon return from home visits. To monitor and log the corning and going of residents on free time and visits. f 4� Responsibilities to the Board of Direc or= To be a public advocate for the Echo Ranch mission. To attend all required meeting_, including those called by the Board of Directors. To participate in the continuing education provided by the Board of Directors,the Department of Social Services, the state, and other agencies. To file an annual professional growth plan that will be approved by the evaluation committee of the Board of Directors. To attend and participate in quarterly evaluation sessions conducted by a representative of the evaluation committee of the Board of Directors. Resoons i b i l i t i es. to Aoenc i es To maintain good working relationships with service agencies, schools, 1arra enforcement and the community at large. To report and record ail school absences, work with school programs and provide progress reports to the schools when appropriate. To attend all special education meetings called by the schools for the residents of the home. To attend all meetings called by the schools about residents such as parent conferences, disciplinary referrals, bus conduct reports, etc. Fo make maximun use of the support systems provided by the Board of Directors, the Department of Social Services, Mental Health, or schools. Financial Responsibilities To be responsible in accounting for all funds allocated to the home and to use and stay within the guidlines of the accounting procedures established by the Board of Directors of Echo Ranch. To purchase all needed supplies and materials for the home such as food, clothing, and sundries, C_; C: � r x `.ither__ Res.Rons i b i ? i tes To perform all other duties as assigned and as outlined in the policies and procedures of the Echo.Ranch Group Home _ __ r -8 EXHIBIT B ADMISSION POLICIES: ECHO RANCH . For each child admitted to Echo Ranch the following must be accomplished: 1) the child must meet the admission criteria outlined in attachment titled "Admissions Criteria." 2) A social study of the family situation and the child's needs must be obtained. (Social Services may provide if child is a court placement) 3) The necessary documents and information about the child must be obtained and attached to the Record of Admission (sample attached) If placement is made through the Department of Social Services the caseworker assigned to the case will be responsible for filling out the admission forms and procuring all needed records. 4) If child abuse is suspected the child shall be examined by the house parents to determine if evidence of physical abuse is present. Where appropriate (if severe physical injury is suspected, or sexual abuse is suspected) an examination at the Vail Valley medical facility is required. A written report of any evidence of abuse shall be placed in the child's record. a) If abuse is suspected and has not been reported a report must be made to the County Social Services Department. 5) All children admitted on other than emergency placement will have an examination by a physican or nurse practitioner the examination will be completed prior to admission or no more than 10 days after admission to Echo Ranch. The record of this exam shall be placed in the child's record at Echo Ranch This exam will be required every two years for children in long-term care. (a sample health evaluation form is attached) 6) A case plan must be developed for each child admitted to Echo Ranch. The case plan will detail the projected length of stay, desired behavioral changes, and the conditions necessary for discharge.. (see attached sample) 7) The house parent will introduce new admissions to the other children in the home at the earliest convenient time. 8) Each child admitted to the Ranch will be given an orientation to the rules for conduct and behavior within 24 hours of admission. 9) All placements will be reviewed by the house parent and the case- worker at the end of the first 30 days of placement. A decision will be made at that time to continue or terminate the placement. This reference pertains only to placements made through the Eagle County Social Services Department 10) All placements made through the Department of Social Service will be reviewed every six months by the Child Protection Team sitting as a placement review committee. 7 V, 11) All placements at Echo Ranch will be approved by the Admissions Committee within the first seven days of placement at Echo Ranch. The Admissions Committee will be comprised of the houseparents, one social worker who is assigned as liaison to Echo Ranch, and one member of the special education staff of the Eagle County School District. 12) When a request for admission is received for a child who is not a resident of Eagle County the request must be reviewed by the Admissions Committee prior to arrival at Echo Ranch. In ADMISSION CRITERIA: ECHO RANCH Preference shall be given to the residents of Eagle County. Children admitted to Echo Ranch shall be between the ages of 11 years, 11 months, 30 days; and 17 years, 11 months, 30 days. An extension may be granted to allow a resident to complete his/her high school education. All residents shall be in good health and free of communicable diseases at the time of admission. Admission shall be denied to all children who are drug or alcohol dependent. Children who are admitted to Echo Ranch may be diagnosed as emotionally disturbed. Psychotic children, or those diagnosed as explosive personalities who might be a danger to other children will be denied admission. Preference will be given to children whose social histories indicate that admission to Echo Ranch will facilitate their personal growth and that the period of residence at Echo Ranch will enhance their long-term adjustment to home, school, and society. No more than ten children shall be admitted to Echo Ranch at any one time. In case of emergency two additional children may be admitted for periods not to exceed 48 hours. These emergency admissions shall be court placements or placements agreed upon by the house parent and the Sheriff's Departments when that department has a child under the age of 18 for whom placement in the County Jail would not be appropriate. In no case will the house parent accept a proposed placement from the Sheriff's Department when the child is suspected of a felony, or is under the influence of drugs or alcohol. When an emergency placement is requested by law enforcement officials the placement will be coordinated by the Sheriff's Deputy who is assigned the responsibility for liason with institutions for juveniles. The house parent will have the option of requesting an evaluation by a licesnsed physician if drug or alcohol intoxication is suspected. When human services agencies outside of Eagle County request a placement at Echo Ranch the following must be accomplished Prior to admission of the child. All records and pertainent data must be presented for review by the Admissions Committee. The child must not be an identified special education child who has been receiving special education services under any handicapping condition unless the actual costs of educating the child in the Eagle County schools are paid by the sending district, social service agency, or private individual. All necessary paperwork assuring an orderly tranfer to the Eagle County School District must be completed. This Includes provisions for tuition or other costs, signatures for release of records, and the names of contact persons in the sending school district. The Eagle County School District has reserved veto power over any prospective admission from outside of Eagle County. 01 MEDICAL POLICY: ECHO RANCH All childen admitted to Echo Ranch shall have a medical evaluation by a licensed physician or nurse practitioner prior to, or within 10 days of their admission to the home. Each child shall have a re-evaluation of their medical status every two years. Each child shall have a dental check-up scheduled every six months. If the child is still in parental custody emergency treatment permission forms must be signed by the parent upon admission of the child. If the custodial parents have medical insurance arrangements must be made to insure that coverage will extend to the child for the duration of that child's stay at Echo Ranch. The house parent has the responsibility to communicate necessary information and prescription drugs to the school nurse of the school in which the child is enrolled if appropriate. The house parent has the responsibility to obtain permission for prescription drugs and administration of emergency treatment for the school if parental rights have been temporarily or permanently terminated. This may entail asking the Social Services caseworker to go to the school to complete the required forms. In case of accident, Injury, or Illness the houseparent will fill out the necessary report and place it in the child's permanent file. (sample attached) A locked case will be maintained in the office of the houseparent. All Prescription and "over-the-counter" medications will be kept in the case which will be locked unless medications are being dispensed. Only the house parent will dispense medications, this authority may not be delegated to any of the residents of the ranch. The house parent will have the responsibility'to determine if a resident is too iIl to attend school. If any child is at home from school because of illness the house parent (or another competent, trained adult) must be present at all times. An agreement for medical services shall be negotiated with a licesnsed Physician in the county. This agreement should include the terms and conditions for treatment of the residents of Echo Ranch. The physician must agree to treat Medicade patients as many of the children at the ranch will be receiving that benefit. A similar agreement should be established with the Vail Valley Medical Center and the Glenwood Springs Community Hospital for inpatient care of residents should such care become necessary. Whenever possible the family physician of choice of the resident should be used to treat the injuries or illnesses of the residents of Echo Ranch A medical record shall be included in each child's personal file. The medical record shall include immunization records, chronic medical problems, Prescribed medications, and a statement of other medical needs such as allergies, other medical concerns, their Medicade number, date of scheduled re-evaluation, dates of scheduled preventive dentistry visitations, and any other pertainent data. The house parent should not sign permission for medical evaluation, emergency treatment, immunizations, or any form of medical treatment unless the child Is in fact in the legal custody of the house parent. Prescriptions for medication written by a physician will be paid for by the parents of the child or by medicaid. In the latter case the pharmacy should be given the child's medicaid number when the prescription is presented and the pharmacist informed that the county social services should be billed. a DISCIPLINE POLICY: ECHO RANCH The house parent shall model appropriate social behavior at all times. Physical punishment shall not be used as a form of discipline for the residents of Echo Ranch in any case. Physical restraints shall not be used on any of the residents of the ranch at any time. The only appropriate method of restraining children Is to hold them using only the hands and arms. Children are never to be punsished by witholding food or drink. Deprivation of privleges is the approporiate method of punishing children for Infractions of the rules of the ranch. Isolation, for appropriate lengths of time, may be used as punishment for disruptive behavior. A point system may established by the houseparent. Residents may earn points for expected behavior as completing chores, helping with assigned kitchen tasks, keeping his/her own personal area neat and clean, completing assigned homework, etc. Points may be used to engage in social activities such as going to a school dance, going on "special" ranch outings as going to the Glenwood pool, or attending a movie. The house parent will be responsible for maintaining the records for such a system. The supevisor from the county Department of Social Services may assist in developing and maintaining the system. Children residing at Echo Ranch are to be supervised at all times. Attendance at school.is considered appropriate supervision. Residents will depart from school in approved transportation, to do other wise is a violation of the ranch rules and will result in suspension of privileges for an appropriate period of time. Children over 16 years may be allowed periods of unsupervised time away from the ranch if it is so stipulated in the case plan. All of the residents of the ranch, including house parents or relief parents, are to attend regularly scheduled group counseling sessions conducted by Social Services or their designated therapists. House meetings for discussion of the rules, regulations, and procedures for running the ranch will be conducted weekly by the house parent. General Rules Each resident is responsible for her/his personal hygiene and their personal area. Beds are to be made each morning before breakfast, sheets are to be changed weekly, personal items are to be removed from the bath area after each use. Each resident is expected to mantain the "quiet time" between 7 and 8 P.M. so that required homework can be completed. If a child does not have homework she/he may study, write, or read quietly. Residents under 14 years are to be in bed ready for sleep before 9:30 Sunday through Thursday. On weekends this time may be extented until] 10:30 P.M. Residents 16 years and older must be in bed by 10:00 on school nites unless a special privilge has been granted from points earned. On weekends the residents over 16 are expected to be in bed ready for sleep by 12: P.M. Each resident of the ranch will be assigned duties on a bl-weekly basis. The duties will be assigned by the house parent and will include the chores necessary for the maintainence of the ranch house and grounds. Helping with the cooking and cleaning are considered a normal part of a well integrated family and are not punishment and should not be used for such. Point values will be assigned to each chore and awarded to residents who complete their task successfully. Failure to complete an assigned task, such as taking out the garbage on a daily basis, will result in the requirement to complete the task without earning any points. Defiance or disobeying a request to complete a task will result in the subtraction from the child's total of the points normally awarded for task completion. Telephone calls are to be made and received only between the hours of 8:00 A.M. and 9:00 P.M. Calls are limited to 5 minutes unless the call is to/from a parent in which case the limit is 10 minutes. Long distance calls are not to be charged to the house phone, they must be charged to another phone or made collect. Residents may invite guests to the ranch for dinner only with prior Permission of the house parent. Permission must be obtained 3 days prior to the planned visit so that the house parent has an opportunity to contact the parents of the guest to gain their approval for the visit. Overnight visits of children who are not related to the resident are not allowed. Siblings of the residents may visit, if there is room, if the house parent and the case worker agree that such a visit is in the best interest of the resident. Residents are required to engage in all planned activities of the ranch. The house parent should use care and concern in planning activities so that most of the children will engage in such activities willingly. (avoid activities that present a clear and present danger to the children) } SPECIALIZED SERVICES: ECHO RANCH Group Counseling Group counseling will be conducted weekly by a mental health professional whose services shall be arranged by the county Department of Social Services. These meetings are mandatory for all residents and house parents. This counseling group is separate from the weekly meeting of the residents and house parent which is used for administrative details of running the ranch. Group counseling sessions shall be for 50 minutes weekly. Individual Counseling Where individual counseling is determined to be necessary it will be conducted by a mental health professional from the Colorado West Mental Health Center. If a child is eligible for Medicaid this eligibility will be used to pay for the counseling. It is possible that counseling may be obtained through the school if the child has been classified for purposes of receiving services through special education. The appropriate ciass- Ification is Significant Identifiable Emotional or Behavioral Disorder (SIEBD). If the child is a placement from another county the sending county shall be responsible for the expenses incurred for delivery of the appropriate services. In many cases counseling services can be del- ivered to the child at school. House Meetings House meeting will be scheduled weekly by the house parent. The purpose of this meeting Is to assign responsibilities and chores for the coming week. Rules of the ranch may be discussed and clarifications and explanations of the rules may be undertaken. The caseworker from Social Services who is delegated liason duties to Echo Ranch should attend these weekly meetings. The caseworker must attend at least one meeting per month. Recreational activities The house parent should work closely with the schools to help insure that the residents of the ranch have an active recreational life. Planned group activities such as hikes, fishing, and camping will be planned to include a majority of the residents. Residents will not be forced to engage in any activity that is against their religious beliefs or incompatible with their physical or medical condition. Hazardous activities such as rock climbing, hang gliding, or parachuting are forbidden. Case Reviews Periodic case reviews will be held to determine the progress of each resident. The reviews will conducted by the caseworker liaison and the houseparent. The caseworker assigned to each child reviewed will be present. Modifications of treatment plans, implementation of, or termination of individual counseling, and recommendations for discharge will be discussed. If possible significant others such as therapists or probation officers will be invited to discuss a particular child. RECORD OF ADMISSION TO THE SPECIALIZED GROUP FACILITY 1) Date of Placement Anticipated length of Placement 2) Child's Name B.D. Medicaid No. 3) Physical Description of Child: Sex Height Weight Hair Color Eye Color Distinguishing Features Describe external evidence of abuse Reason for placement 4) Mother's Name Address Father's Name Address Siblings - Number Ages Placement? Phone Phone Sex 5) Individual or agency having legal custody or guardianship of the child and who is authorized to place the child in, or remove the child from.foster care: Name Phone Address 6) Child's Caseworker 7) Child's Doctor Address 8) Child's Dentist Address Phone Phone Date of Last Checkup _ Phone Date of Last Checkup - Record of Admission to the Specialized Group Faci,-ty (continued) 9) Last School Attended Grade Address Date of Withdrawal Past School Performance 10) Religious Preference or Affiliation 11) Does Child Have Driver's License What Insurance Coverage 12) Medications in use at time of placement: Name Dosage Date Begun Expected Completion Refill Information 13) List any chronic or handicapping problem which the child has; e.g. seizures, asthma, allergies, diabetes, heart disease, respiratory illness, drug reaction: Describe symptoms and give instructions for care for any of the above mentioned conditions (use separate sheet if necessary): 14) Check illnesses which the child is known to have had: Measles German Measles _ Chickenpox Mumps Scarlet Fever Strep Throat Rheumatic Fever Other 15) Describe child's behavior such as suicide attempts, runaway, violent outbursts, depression, stealing, fire setting, sulking, excessive crying, enuresis 16) List phobias such as heights, animals, darkness, water Record of Admission to the Specialized Group Facility (continued) r 17) Describe child's habits as to eating, sleeping, snacking, drugs, nervous habits, other 18) Special needs of child -and services of group home making it the most appropriate placement. Documents which should be attached to Record of Admission I. Social Study (include relationship of child with adults and peers - previous. placements - special skills and abilities) 2. Authorizations for emergency medical care pursuant to policy and procedures of home (A -7464.1(4c)) 3. Physician's Statement 4. Birth Certificate (if available) 5. School Records (if available) 6. Health and Immunization Records (if available) ` CHILD'S HEALTH EVALUATION FORD] Dear Physician: The completion of this statement is necessary for this child to be cared for in a family foster home. Child's Name Address Sex Height Birth Date Weight If tuberculin test given: Date: Result If chest x-rayed: Date: Result Surgery, accidents, illnesses, chronic or handicapping problems Need for medication or special diets Immunizations: Date of completed primary or latest booster- Type: Date Type Type: Date Type Physical findings (include, if tested, vision and hearing) Date Date Comments and Recommendations to family foster parents: (include recommendation for other laboratory and medical tests) Date Doctor's signature Doctor's telephone number rte:..., CASE PLAN OUTLINE Child's Name Date 1) Target behavior or anticipated behavioral changes Timing; 2) Anticipated Methods; (to be used by group facility parents/personnel or ancillary treatment) 3) Approved visits with parents/peers/others 4) Date of next periodic evaluation; Caseworker Primary Caregiver (Signature) Ic (Signature) I V, 1) Describe child's behavior: 2) - Goal(s) achieved: 3) Reason for discharge: To whom discharged Agency (if appropriate) Date of discharge Primary Caregiver SAMPLE DISCHARGE PLAN Child's Name Date Position INJURY, ACCIDENT ILLNESS OR FATALITY REPORT To be filled in by a foster hcme parent in case of accident or injury occurring to a foster child resulting in medical treatment, hospitalization or death, and submitted to the licensing or certifying agency -immediately following the occurrence. Name of foster parent reporting Address Name of child Name of Individual or Agency with legal custody of child Address City Witness to Accident Address Age Please explain the type and the circumstances of the child's accident or injury; include date, time and location (use the back of the form, or additional sheets if necessary) Describe any action taken or treatment given to child in the home Treatment given by Attending Physician's Name (if any) Hospital, clinic or other treatment facility to which the child was taken Address Check if child is still there. How was the child transported to the hospital or clinic If the foster homes' insurance was utilized, give name and address of insurance c,mpany. Signature of foster home parent I)a to