I Will Be Responsible for Disciplining Children in My Care and Not Delegate This Responsibility

/ CHILDREN’S ADMINISTRATION
DIVISION OF LICENSED RESOURCES
Policy Agreements
NAME / DATE
PLEASE SIGN EACH SECTION
DISCIPLINE
WAC 388-148-0465

1. I will be responsible for disciplining children in my care and not delegate this responsibility to a child.
2. Any discipline of a child under my care will be based on an understanding of the child’s needs and stage of development.
3. Discipline will be designed to help the child develop inner control, acceptable behavior and respect for the rights of others.
4. Discipline will be fair, reasonable, consistent and related to the child’s behavior.

WAC 288-148-0470

1. I will not use cruel, unusual, frightening, unsafe or humiliating discipline practices. These include but are not limited to:

a) Spanking children with a hand or object;
b) Biting, jerking, kicking, hitting, or shaking the child;
c) Pulling the child’s hair;
d) Throwing the child;
e) Purposely inflicting pain as a punishment;
f) Name calling, using derogatory comments;
g) Threatening the child with physical harm;
h) Threatening or intimidating the child; or
i) Placing or requiring a child to stand under a cold water shower.

1. I will not use methods that interfere with a child’s basic needs. These include, but are not limited to:

a) Depriving the child of sleep;
b) Providing inadequate food, clothing, living space or shelter;
c) Restricting a child’s breathing;
d) Interfering with a child’s ability to take care of their own hygiene and toilet needs; or
e) Providing inadequate medical or dental care.

1. I will not use methods that deprive a child of necessary services. These include, but are not limited to, contacting;

a) The assigned social worker;
b) The assigned legal representative;
c) Parents or other family members who are identified in the case plan; or
d) Individuals providing the child with therapeutic activities as part of the child’s service plan.
Please use this space to describe your discipline practices using examples and specific age groups:
PRIMARY CONTACT SIGNATURE / DATE
SECONDARY CONTACT SIGNATURE / DATE
RELIGION
WAC 388-148-0430 – I understand that:

1. I may have a child attend church services, temple, or synagogue, if the child chooses to participate.
2. I must respect the religious rights of the children under my care.
3. Children have the right to practice their own faith.
4. Children have the right not to practice my faith without consequences.

a)Please use this space to describe your supervision plan for children who choose not to participate in your religious or spiritual practices.
b)How will you support and respect the religious rights of the children in your care if they choose to engage in religious or spiritual practice different from yours?
PRIMARY CONTACT SIGNATURE / DATE
SECONDARY CONTACT SIGNATURE / DATE
CULTURE AND BASIC NEEDS
WAC 388-148-0505
I agree to meet the child’s basic needs and to support the child’s cultural identity. If I receive a child into my care that I do not have the knowledge and skills to support the child’s cultural identity, I will request assistance from the child’s caseworker to gain these skills.
How will you support the cultural / identity needs of a child of a different ethnicity or culture than your own?
PRIMARY CONTACT SIGNATURE / DATE
SECONDARY CONTACT SIGNATURE / DATE
NATIVE AMERICAN CHILDREN’S RIGHTS

1. I agree to support the cultural and identity needs of Native American children and comply with all state and federallaws regardingof Native American children under my care.
2. I agree to abide by all culturally specific case plans for Native American children.

PRIMARY CONTACT SIGNATURE / DATE
SECONDARY CONTACT SIGNATURE / DATE
CONFIDENTIALITY
RCW 74.04.060

1. The department and its employees are prohibited from disclosing the contents of any records, files, papers, and communication, except for purposes directly connected with the administration of the programs. Foster parents are subject to the same rules of confidentiality as paid department staff.

WAC 388-148-0130

1. I understand that information about a child or the child’s family is confidential and must only be shared with people directly involved in the case plan for the child.
2. I agree to consult with my licensor or the child’s social worker for guidance about sharing information with others involved in the child’s case plan.

CA Operations Manual 43022
I will confirm with the social worker if there are any safety reasons why unidentified photos of children placed in my home may not be posted on my social networking site (no names, identification of child as a foster child or case specific information about the child or the child’s family).
PRIMARY CONTACT SIGNATURE / DATE
SECONDARY CONTACT SIGNATURE / DATE
SMOKING
WAC 388-148-0185

1. I understand that I will prohibit smoking in the living space of any home or facility caring for children and in motor vehicles while transporting children.
2. I also understand that nothing in this section is meant to interfere with traditional or spiritual Native American ceremonies involving the use of tobacco.

PRIMARY CONTACT SIGNATURE / DATE
SECONDARY CONTACT SIGNATURE / DATE
SUPERVISION
WAC 388-148-0460

1. I understand that I must provide or arrange for care and supervision that is appropriate for the child’s age, developmental skill level, and condition (including supervision of children who help with food preparation in the kitchen, based on their age and skills).
2. I will not leave preschool children and children with severe developmental disabilities, unattended in a bathtub or shower.
3. I will provide the children in my care with appropriate supervision, emotional support, personal attention, structured daily routines and living experiences.
4. I will supervise children during sleeping hours with at least one awake staff when it is part of the written supervision plan with the child’s social worker.
5. I will arrange and maintain adequate supervision during times of crisis when one or more family members or staff members may be unavailable to provide the necessary supervision or coverage for other children in care.
6. I understand that special supervision arrangements may be required when the child’s social worker and I agree to a supervision plan (foster parents are encouraged to work with the child’s social worker to develop a child-specific supervision plan).

I agree to comply with all the above requirements and provide appropriate supervision to foster children in my care.
PRIMARY CONTACT SIGNATURE / DATE
SECONDARY CONTACT SIGNATURE / DATE
REPORTING RESPONSIBILITIES
WAC 388-148-0120
I understand that I must report any of the following incidents immediately and in no instance later than 48 hours to my local children’s administration staff:

1. Any reasonable cause to believe that a child has suffered child abuse or neglect;
2. Any violations of the licensing or certification requirements where the health and safety of a foster child is at risk and the violations are not corrected immediately;
3. Death of a child;
4. Any child’s suicide attempt that results in injury requiring medical treatment or hospitalization;
5. Any use of physical restraint that is alleged improperly applied or excessive;
6. Sexual contact between two or more children that is not considered typical play between pre-school age children;
7. Any disclosures of sexual or physical abuse by a child in care;
8. Physical assaults between two or more children that result in injury requiring off-site medical treatment or hospitalization;
9. Physical assaults of foster parent or staff by children that may result in injury requiring off-site medical attention or hospitalization;
10. Any medication that is given incorrectly and requires off-site medical treatment;
11. Serious property damage that is a safety hazard and is not immediately corrected or may compromise the continuing health and safety of children; or
12. Any emergent medical care (including unexpected health problems that require off-site medical treatment).

I understand that I must report the following incidents to the child’s social worker immediately or in no instance later than 48 hours:

1. Suicidal/homicidal ideation, gestures, or attempts that do not require professional medical treatment;
2. Unexpected health problems that do not require professional medical treatment;
3. Any incident of medication incorrectly administered;
4. Physical assaults between two or more children that result in injury but did not require professional medical treatment;
5. Runaways; and
6. Use of physical restraints for routine behavior management.

I agree to comply with the above reporting requirements.
PRIMARY CONTACT SIGNATURE / DATE
SECONDARY CONTACT SIGNATURE / DATE
FIREARMS AND SUPERVISION
WAC 388-148-0190

1. I understand that firearms, ammunition, and other weapons must be kept in locked container, gun cabinet, gun safe, or another storage area made of strong, unbreakable material when not in use.

a)If the storage cabinet has a glass or another breakable front, the guns must be secured with a locked cable or chain placed through the trigger guards.
b)Ammunition must be stored in a place that is separate from weapons or locked in a gun safe.
c) Weapons and ammunition must be accessible only to authorized persons.

1. I understand that I may allow a child to use a firearm only if:

a)The child’s social worker approves;
b)Competent adults are supervising use; and
c)The youth has completed an approved gun safety or hunter safety course.
No firearms exist in my/our foster home and I/we agree to notify my licensor if I/we bring any into the home
Or
Firearms exist in my/our foster home.
PRIMARY CONTACT SIGNATURE / DATE
SECONDARY CONTACT SIGNATURE / DATE
WATER SAFETY AND SUPERVISION
WAC 388-148-0170

1. I will ensure that children under my care or placed in my home or facility are safe around bodies of water.
2. I will daily empty and clean any portable wading pool that children use.
3. I will ensure that children under twelve are in continuous visual or auditory range at all times, when the children are swimming, wading, or boating, by an adult with current age appropriate first aid and CPR.
4. I will ensure age and developmentally appropriate supervision of any child that uses hot tubs, swimming pools, spas, and around man-made and natural bodies of water.
5. I will ensure that all safety devices and rescue equipment, such as personal flotation devices meet state and federal water safety regulation.
6. I will lock or secure hot tub and spa areas when they are not in use.
7. I will place a fence designed to discourage climbing and have a locking gate around a pool or have another DLR approved safety device. The pool will be inaccessible to children when not in use.
8. I will ensure that If I have a pool or water hazard on my premises, I will have a written licensing safety and supervision plan to ensure the safety of children in my care.
9. I will ensure that individuals supervising children in my home know how and be able to use rescue equipment or have a current life-saving certification, when children are using a pool on my premises.
10. I understand that all group care facilities and staffed residential homes licensed for six children must have a person with current life-saving certification on-duty when children are using a pool at the facility.

PRIMARY CONTACT SIGNATURE / DATE
SECONDARY CONTACT SIGNATURE / DATE
MEDICALPOLICY STATEMENT
HOSPITAL / DOCTOR
As a foster parent, I agree to:

1. Report any serious injury or illness to a child’s social worker;
2. Maintain health history and update immunizations for the foster children in my care;
3. Follow recommended hand washing practices to protect myself and the child from the spread of germs; and
4. Follow through on all agency approved medical treatment which may include counseling.

Per WAC 388-148-0470

• I will not use medications in an amount or frequency other than that prescribed by a physician or psychiatrist.
• I will not use medications for a child that I have been prescribed for someone else.

Describe your plan of action to be taken in the event of a medical emergency:
PRIMARY CONTACT SIGNATURE / DATE
SECONDARY CONTACT SIGNATURE / DATE
IMMUNIZATION FOR MY CHILDREN
WAC 388-148-0340
COMPLETE A OR B
A.I am attaching a statement from my health care provider that indicates my children are up to date with the immunizations listed in the chart below. I will continue to keep them up to date on these immunizations. I will contact my licensor if anyone in my home contracts any of the illnesses listed in the chart below to be on stop placement until the contagion passes. If I am contacted for a placement, I will decline until the contagion has passed. I will contact my licensor when the contagion has passed so the stop placement may be lifted.
VACCINE / ILLNESSUSUAL INCUBATION PERIOD
Chickenpox...... 14 to 16 days after exposure, with a range of 10 to 21 days. Chickenpox can spread from 1 to 2 days before rash appears until all the chickenpox blisters have formed scabs.*
Diptheria...... 2-5 days (range of 1-10 days).*
Hib...... The incubation for Hib is unknown, but it is probably less than one week per the New York State Department of Health.
Measles...... Averages 10-12 days. From exposure to rash onset averages 14 days.*
Mumps...... 14 to 18 days (range of 14 to 25 days).*
Pertussis...... Symptoms may develop for as long as 6 weeks after exposure. The incubation period of Pertussis is commonly 7-10 days (with a range of 4 to 21 days).*
Polio...... Commonly 6-20 days (with a range of 3 to 35 days).*
Pneumococcal...... Major clinical syndromes of pneumococcal disease are pneumonia, bacteremia, and meningitis. The incubation periods vary depending on which of the three major conditions are present.*
Rotavirus (vaccine by 8 months)...Approximately 2 days.*
Rubella...... 14 days ( with a range of 12 to 23 days).*
*Per Center for Disease Control and Prevention
PRIMARY CONTACT SIGNATURE / DATE
SECONDARY CONTACT SIGNATURE / DATE
B.Check one or both if A above is not completed.
A child of mine has a medical condition which makes immunizations not advised.
I have a religious, philosophical or personal objection to immunizations.
I will contact the licensor and the placement desk to be put on a stop placement if I learn my family has been exposed to or has an illness listed in the chart above. If I am contacted for a placement, I will decline until the contagion has passed. I will contact my licensor when the contagion has passed so the stop placement maybe lifted.
PRIMARY CONTACT SIGNATURE / DATE
SECONDARY CONTACT SIGNATURE / DATE
CA DLR AA SIGNATURE / DATE
FIRST AID SUPPLIES AND MEDICATION STORAGE
WAC 388-148-0200

1. I will keep first aid supplies, and additional medication recommended by a child’s physician on hand for immediate use.
2. The following first aid supplies must be kept on hand.

a) Barrier gloves and one-way resuscitation mask;
b) Bandages;
c) Scissors and tweezers;
d) Ace bandage;
e) Gauze; and
f) Thermometer.
WAC 388-148-0205

1. I will keep all medications, including pet medications, vitamins and herbal remedies, in locked storage.
2. Pet and human medications must be stored in separate places.
3. You must store external medications separately from internal medications.

PRIMARY CONTACT SIGNATURE / DATE
SECONDARY CONTACT SIGNATURE / DATE
PUBLIC DISCLOSURE
The Public Records Act, Chapter 42.17 RCW, governs access to and disclosure of public records. CA is required to make identifiable public records promptly available for inspection and copying upon request by any person unless nondisclosure is required or authorized by law. RCW 42.17.28.
I have read and reviewed the WAC booklet and agree to comply with all licensing requirements.
PRIMARY CONTACT SIGNATURE / DATE
SECONDARY CONTACT SIGNATURE / DATE

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DSHS 10-290 (REV. 03/2012)