<%@ LANGUAGE="VBSCRIPT" %> <%option explicit%> <%Response.Buffer=true%> Dept of Juvenile Justice Certificate of Placement <%Sub Print_Certificate%>
<%'Response.ContentType = "application/msword"%><%'Response.ContentType = "application/pdf"%><%'Response.AddHeader "content-disposition", "filename=*.doc"%> <% For i = 1 to lPgmServCnt lCopay = aCopay(i) lCopayType = aCopayType(i) If lCopay <> "" Then If lCopayType = "$" Then lCopay = FormatCurrency(lCopay) lCopayType = "" End If End If lCopayAgency= aAgency(i) lPerdiem = aPerDiem(i) If lPerdiem = 0 Then lPerdiem = "" Else lPerDiem = FormatCurrency(lPerDiem) End If lMonthlyRate = aMonthlyRate(i) If lMonthlyRate = 0 Then lMonthlyRate = "" Else lMonthlyRate = FormatCurrency(lMonthlyRate) End If lServiceDesc = aServiceDesc(i) %> <%Next%><%=lcopayagency%>

 

 

 

 

 

 

 

 

 

 

 

CERTIFICATE OF PLACEMENT

 

 

 

 

 

 

 

 

 

 

 

Placement Auth #:

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Date:

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Authorized by:

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YOUTH IDENTIFICATION

 

 

 

 

 

 

 

Youth's Name:

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DOB:

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Assist #:

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CO:

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Area:

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Current Placement:

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Proj. Admission:

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Proj. Discharge:

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Case Manager:

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Resource Coordinator:

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FINANCIAL AGREEMENT

 

 

 

 

 

 

 

Program Name:

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Program #:

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Program Address:

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Vendor:

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Vendor Address:

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Vendor Phone/Fax:

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Costs assumed by the State of Maryland Department of Juvenile Services(DJS):

Per rates established within the current contract between this facility and DJS for the following services:

 

Service

Per Diem

Per Month

DJS
Share

with Agency

 

 

 

 <%=lServiceDesc%>

 

 <%=lperdiem%>

 

 <%=lmonthlyrate%>

 

 <%=lCopay%>

 

 <%=lcopaytype%>

 

Special Notes:

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CUSTODY

 

 

 

 

 

 

 

 

Admission Date:______________   Received by(Sign): ____________________________   (Print): ____________________________

 

 

 

 

 

 

 

 

 

 

Admission Date:______________   Delivered by(Sign): ___________________________   (Print): ____________________________

 

 

 

 

 

 

 

 

 

 

Discharge Date:_______________   Received by(Sign): ___________________________   (Print): ____________________________

 

 

 

 

 

 

 

 

 

 

Discharge Date:______________   Discharged by(Sign): ___________________________   (Print): ____________________________

 

 

 

 

 

 

 

 

 

 

AGREEMENT

 

 

 

 

 

 

 

 

This agreement is made pursuant to the Department of Juvenile Services standard contract and all provisions of that contract hold true.

 

 

 

 

 

 

 

 

 

 

For Department of Juvenile Services

For Child Care Facility

 

 

 

 

 

 

 

 

 

 

____________________________________

____________________________________

(Name)

(Authorized Representative)

 

 

 

 

 

 

 

 

 

 

____________________________________

____________________________________

(Date)

(Date)

 

 

 

 

 

 

 

 

 

 

c: Case Manager, Case Manager Supervisor, Placement Unit, Budget, Resource Office

<%End Sub%>