Effingham CASA Family Visitation Room - Agency Agreement & Reservation Request
ALL QUESTIONS MUST BE ANSWERED TO REQUEST A RESERVATION
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Agency Name: *
Visit Supervisor Name: *
Visit Supervisor Phone Number: *
Visit Supervisor E-mail: *
Family Name of Requested Visitation Time: *
Date of Requested Room Reservation: *
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Start Time of Requested Room Reservation: *
Time
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End Time of Requested Room Reservation: *
Time
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For recurring visits, please check all that apply: *
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Comments:
Agency Agreement (Hard copy will be emailed to you for agency signature upon reservation confirmation)
Please read and check that you understand and agree below.
CASA Family Visitation Room ** This agreement is designed with safety, confidentiality, and team work in mind **• We follow DCFS visitation guidelines. The investigation/case/service plan/court/return home/the foster placement/the other parent shall not be discussed during the visit. No other cases shall be discussed.• If room is in use upon arrival, please wait in the hallway until the previous visit has ended (if past your start time, please knock and let the party know your visit time is starting).• Do not share door access code with clients.• Sanitize your hands upon arrival with provided hand sanitizer.• Do not leave the children unattended at any time.• Keep cell phone usage and other distractions to a minimum so that you can properly monitor the conversations and interactions of the parents and children. • Please make sure that the space you and the family have used has been picked up; clean before leaving - including the floor if needed (using the battery powered sweeper). Sanitize any used area with antibacterial wipes: table & chairs, couch, rocking chair. Place played with toys in “Used” laundry basket. Dispose of used disposable changing table pad in trash can and replace with clean pad. Dispose of all trash and dirty diapers in the trash can.• Please make sure the family takes all their personal belongings with them at the end of their visit.• No smoking, no illegal drugs, no weapons, no alcohol, no foul language. Absolutely no violence or corporal punishment.• During the visit, if you are inappropriate in any manner, you will be asked to leave, and the visit will be terminated. If asked to leave, please do so without any disruption, causing less impact on the children. If you do not leave when asked, the police will be called to escort you out of the building.• If utilizing the Observation Room, face masks must be worn over nose and mouth while two (2) or more people are present.• Three (3) No Show/No Notice missed visits will cause you to be removed from the room schedule. You may reapply for your requested time, but it may no longer be available.• If any issues with the room arise between 8 am-4 pm, please visit our CASA office in Suite 211. After 4 p.m., please call 217-500-0117. *
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I understand that my submission of this form does not guarantee my reservation. I understand that CASA will email me with confirmation of my reservation and copy of the Agency Agreement for me to bring to my first visitation with this family. I understand that the family will also be required to sign an agreement at the first visit to use the Visitation Room. I understand that my Agency name, Supervisor Name, and Family initials will be displayed on the room online calendar. *
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To cancel or alter a visit date or time, please contact CASA at jpatnaude@casa4change.org or  217-342-2266. *
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