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New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection & Permanency

Effective Date:

Volume:

X

Forms

Chapter:

A

Forms

 

2-5-2018

Subchapter:

1

Forms

Issuance:

11.5

CP&P Form 11-5, EIS Parental Consent Form

 

 

Click here to view or print the CP&P Form 11-5.

 

Click here to view or print this form in Spanish, CP&P Form 11-5(S).

 

PURPOSE AND USE

 

Use CP&P Form 11-5, EIS Parental Consent Form, to obtain consent from the identified “parent” when referring a child, three years of age and under, to the New Jersey Early Intervention System (NJEIS). See CP&P-V-A-5-200, New Jersey Early Intervention System (NJEIS) for information to define the “parent” pursuant to federal regulation, 34 CFR 300.30.

 

CP&P Form 11-5 is used by Local Office staff for a child in an out-of-home placement setting. There is no need to use this form when a biological parent maintains care and supervision of his or her own child.

 

INSTRUCTIONS FOR COMPLETING THE FORM

 

  • Enter the date in which the “parent” signs the form
  • Enter the “parent’s” first and last name
  • Enter the child’s first name, middle initial, last name
  • Enter the child’s date of birth
  • The identified “parent” signs and dates the form
  • The witness prints his or her name and indicates their relationship to the identified “parent”
  • The witness signs and dates the form

 

DISTRIBUTION

 

Original          Child’s CP&P Case Record

Copy               CP&P Local Office Child Health Unit Nurse

Copy               Parent/Guardian