ࡱ> }| @ 8mbjbjʚʚ r """"""""X///8oloX>8/0h0h0h0h0C122Dh=>>>>>>$?R:Bz+>"2C1C122+>""h0h0>1515152"h0"h0h=152h=15157""8h0q Pu0>7,B3BB86J""""B"8221522222+>+>XX\!5XX\RELATIVE RESPONSE FORMMichigan Department of Human ServicesAs the child(ren)s relative, DHS needs to know if you want to provide contact, connection or support to the child(ren) and/or to provide a temporary or permanent home to the child(ren). Please indicate your response(s) below.I, FORMTEXT      understand that FORMTEXT      (Relative Name)(Child(ren) s Name)is currently in the custody of Michigan Department of Human Services. If the parents are available, services will begin to return the child(ren) with parent(s). If these services do not remove the safety concerns, DHS will make another permanent plan for the child(ren). The child(ren) is/are in need of family contact, connection and support. The child(ren) is/are also in need of safe, positive temporary placement, and may in the future be in need of a permanent placement.1.Please indicate if you want DHS to consider you for providing the following contacts and support to the child(ren): FORMCHECKBOX Writing letters to the child(ren). FORMCHECKBOX Having phone contact with the child(ren). FORMCHECKBOX Visiting with the child(ren) including holiday visitation. FORMCHECKBOX Having the child(ren) visit you. FORMCHECKBOX Provide transportation for visits. FORMCHECKBOX Providing family history information including photos. FORMCHECKBOX Providing family contact information of other potential relatives. FORMCHECKBOX Providing family medical history. FORMCHECKBOX Other involvement: FORMTEXT      2.Please indicate whether you wish DHS to consider you as a possible temporary placement:(Initial only one) FORMTEXT    Yes. Do consider me as a temporary placement for the child(ren). FORMTEXT    No. Do not consider me as a temporary placement for the child(ren).3.Now indicate whether you wish DHS to consider you as a possible permanent placement:(Initial only one) FORMTEXT    Yes. Do consider me as permanent placement for the child(ren). FORMTEXT    No. Do not consider me as permanent placement for the child(ren).4. FORMCHECKBOX I would like to discuss the child(ren) and their needs more fully with the caseworker.Please contact me at: FORMTEXT       If you wish to be considered as a placement home for the child(ren), please sign, date, and return this form within 30 days. If you do not return this form, DHS may not consider you as a placement resource for the child(ren), and may proceed with another permanent plan for the child(ren). DHS will be making decisions about where the child(ren) lives, the type of contact a child(ren) may have with a relative based on the best interests, and the needs of the child(ren). A relatives criminal history, child ab =?A$ % & ' ( * + , 6 7   , . 0 D F H R T V x z . a b c d 1 2 3 4 5 7 ӹī̧Ӝī픉~hE hMPhp h@h@CJ aJ h@CJ aJ jbhfUhM)jh{.UmHnHujhfUjhfU hMPhfhf hMPhMP hp hp hp hp 5hMP h`h`hp h`/>?@+|eUd`$If^gdI <kd^$$Ifl4y,y,4 lalf4dL$Ifgdz;<kd$$Ifl4y,y,4 lalf4d($IfgdM)mmB@A% & ' |hd$$If^gdp <kd"$$Ifl4-y,y,4 lalf4 $Ifgdp <kd$$Ifl4y,y,4 lalf4' ( +  . 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"Hl! v:f1}7v: $IfgdiJ $IfgdiJ $$Ifa$gdiJd$$If^gdiJOkd$$Ifl4 0hy,h+4 lalf4^u!i`f1W7v: $IfgdiJ $IfgdiJ $$Ifa$gdiJd$$If^gdiJukd$$Ifl4\h, jy,h >4 lalf4ju!i`f1W7v: $IfgdiJ $IfgdiJ $$Ifa$gdiJd$$If^gdiJukdR$$Ifl4\h, jy,h  >4 lalf4^ui`W $IfgdiJ $IfgdiJ $$Ifa$gdiJd$$If^gdiJukdy$$Ifl4\h, jy,h  >4 lalf4u!l1c(v: $Ifgdo/r $Ifgdo/rd$$If^gdo/rukd,$$Ifl4\h, jy,h >4 lalf4os\R]S]T]V]W]a]ȵۢ~|upldljhUh hiJ5 hMPh_xUh@h@CJ aJ hiJhbJh_xh@h_x5 h@5 ho/r5jh{.UmHnHujho/rUjho/rUho/r hE5ho/rhE5\ ho/r5\jh{.UhEjhEU hMPhE#!1vv:1vcv: $Ifgdo/r $Ifgdo/rd$$If^gdo/rbkdH$$Ifl4Fhy,hh)    4 lalf4\vdRB.d$$If^gdfd$If^gd@d$$If^gd@d$If^gd@kd2$$Ifl4rh >+y,hh;4 lalf4use history will also be considered in determining the degree, and type of contact a relative may have with children. DHS will contact you if you expressed: an interest in contact with the child; or a desire to provide a connection or support to the child; or interest in having the child placed with you on a temporary or permanent basis FORMTEXT      (Relative Signature)(Date)Address FORMTEXT      Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex,\\]S]T]U]V]^^ 1 $Ifgdp <kd$$Ifl4y,y,4 lalf4 & Fd$$Ifgd_xa]b]^ ^ ^^^N^P^^^b^d^x^z^|^^^^^^^^`lllmmmxxx&x(x*x>x@xBxǺު}r}}gj#hYqUj"hYqUhYqjhYqUh| h(VU hMPhMP h 7f5jx h 7fUjh 7fUhMPh 7fhyOCJ KH \^JaJ hyOh5CJ KH \^JaJ hjh{.UmHnHujhUj:hU%^^<^>^L^N^}t}t $IfgdyO $$Ifa$gdyOukd$$Ifl4\z>+y,z, ;4 lalf4N^P^`^b^^^y<33 $Ifgd 7f<kd $$Ifl4 y,y,4 lalf4d`$If^gdI ukdj$$Ifl4\z>+y,z, ;4 lalf4^^^^^i<kd!$$Ifl4y,y,4 lalf4 $Ifgd 7fOkd $$Ifl4 0>+y,>+;4 lalf4^^llmmmmm(xPx+|nip,1gp,^eeip,1ca=<gd 7f<kdl"$$Ifl4y,y,4 lalf4$dL$If^a$gdz;<kd"$$Ifl4y,y,4 lalf4 sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. 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