Respite Foster Care Placement Contract

1. Parties

Agency/Organization Name:

Address: Contact Person: Phone / Email:

Respite Caregiver(s) Name(s):

Address: Phone / Email:

Child(ren) Name(s):

Date of Birth: Case # / ID:

2. Placement Details

Start Date	End Date	Location of Respite

3. Responsibilities

• Agency Responsibilities:

• Respite Caregiver Responsibilities:

• Parent/Guardian Responsibilities:

4. Compensation

Rate per Day	Total Days	Total Compensation

Payment Method: Payment Schedule:

5. Emergency Contact Information

Primary Emergency Contact: Phone: Relationship: Medical Facility/Doctor: Phone:

6. Terms and Conditions

7. Signatures