WPC PbQpW;C|y=[Δo"Q;C'A 9E?Cj.ȡUws bݧ,\9o9'J`ImTu'Os AOǽ_WiyiHT"EJV%̈Gј{ygtګ̕@@uL%{(˗hN홁O& { w,LxPW}Nfc.*r P!Ygd5f3aWK{G)M>U >B 0 0A 0)2 0[ 0 } 0hn 0 02 0l 0lg 0 0 D+ 0 0( 0C AQb! 1e) 0r#U N %'N-^ /w;4?S mU 1ul( 72\  `&Times New Roman<l:Default ParaXXX.aa,Title  S\  `&Times New RomanS   S\  `&Times New RomanS4zz2Subtitle  S\  `&Times New RomanS           S\  `&Times New RomanS<:Body Text In X   5+ ` hp x (#5  S\  `&Times New RomanS    8.` hp x (#8  S\  `&Times New RomanS&$1    2(` ` hp x (#2  S\  `&Times New RomanS    8.` hp x (#8  S\  `&Times New RomanS&$2 X   5+ ` hp x (#5S\  `&Times New RomanS    8.` hp x (#8S\  `&Times New RomanS6^^4Body Text  S\  `&Times New RomanS  S\  `&Times New RomanS0m.Footer (#S\  `&Times New RomanSA7X` hp x (#AS\  `&Times New RomanS:8Page Number:8Line Number'    0 .  HAPPLICATION FOR CARE AND/OR FOR(e2k,$ V"!  XXXXXXXX  (e2k,$ V"!  XXXXXXXX  'dxd Level 1 Level 2 Level 3 Level 4 Level 5(e2k,$ V"!  XXXXXXXX  ($(e2k,$ V"!  XXXXXXXX  C<< c- -$35;AGMSY_3a.a.i.1.a.i.1.a.#|x(JV"$  X-XXXX-XXX-HPLJ33000(9 Z6Times New Roman RegularX6Z DM6yFilesU3#37=CIQYag1.a.i.(1)(a)(i)1)a) k,'  XXXXXXXX  _"X C"8/1/07#i)  X V"!  XXXXXXXX  _@VV)104    (/V8XXdd8=XXdd=$APPLICATIONFORCAREBY  LAWENFORCEMENTOFFICER  z PursuanttoK.S.A.382232(c) f   XI,________________________________________,alawenforcementofficerforthe >  ___________________________________,applyforshelterforthefollowingdescribedchild(ren) *  intheprotectivecustodyoflawenforcementforthereasonssetforthbelow:  t  X1.  NameofChild:________________________________________  DOB:___________  L  Ѐ  Address: ________________________________________0  maleorfemale 8  (# (#   ________________________________________ $   X?+ ` hp x (#X?NameofChild:________________________________________  DOB:___________    XB.` hp x (#XBӀ  Address: ________________________________________0  maleorfemale  (# (#   ________________________________________ v   XNameofChild:________________________________________  DOB:___________ N  XӀ  Address: ________________________________________0  maleorfemale: (# (#   ________________________________________ & 2.  Child(_ren_)sParent,ParentsorNearestRelative: \   Name: `  _________________________________________ H   Address: _________________________________________ 4   Phone: _________________________________________   3.  Person(s)WithWhomTheChild(ren)HasBeenResiding:    Name: `  _________________________________________    Address: _________________________________________ r   Phone: _________________________________________ ^  X  ?+ ` hp x (#X? XXXX  ;   4.  I,theundersignedapplicant,believethateachchildnamedaboveisaChildinNeedofCare 6! andthattherearereasonablegroundstobelievethatthecircumstancesorconditionofthe ""  child(ren)issuchthat,unlessplacedintheimmediatecustodyoftheshelterfacilityorother #l! responsibleperson,thechild(ren)wouldbeharmed.; ݌ #X" Ќ X   XX XXXX  XThespecificfactsonwhichIbasethisbeliefareasfollows: %0!$  X  ________________________________________________________________________ &"%  X________________________________________________________________________ '#&  XB.` hp x (#XB X________________________________________________________________________ (#' ________________________________________________________________________ )$( ________________________________________________________________________ n*%) ________________________________________________________________________ Z+&* (/V (X (  ________________________________________________________________________   X?+ ` hp x (#X? X  Further,IunderstandthatitismystatutorydutypursuanttoK.S.A.382232(a)toprovide  theCounty/DistrictAttorney,withoutunnecessarydelay,alltheinformationinmy z possessionpertainingtoeachchild,eachchildsparentsorotherpersonsinterestedinor f likelytobeinterestedinthechild(ren),andallotherfactsandcircumstanceswhichcaused R thechild(ren)tobetakenintocustody. >    XB.` hp x (#XB X_____JuvenileIntakeandAssessmentshouldcontactmepriortoplacementdecision.  t  X   <(` ` hp x (#X< XXXX  -  _____JuvenileIntakeandAssessmenthasmypermissiontomakeaplacementdecision  L  afterreviewingalloptions.-݌  8  Ќ    X` ` X XXXX     <(` ` hp x (#X< XXXX      ݌ $  Ќ    X` ` X XXXX     <(` ` hp x (#X< XXXX  g  _____Notapplicableg݌   Ќ    X` ` X XXXX   X  ?+ ` hp x (#X?XXXX    5.  PursuanttoK.S.A.382217(a)(3),___IdentityofIndividualReceivingCustody__________   maygiveconsenttothefollowing:     p j݌ v  Ќ X   XXXXXX   (43# <(` ` hp x (#X< 2   a  .3   ` Dentaltreatmentbyalicenseddentist; N <(` ` hp x (#` ` X<2   b  .3   ` Diagnosticexaminationsincludingbutnotlimitedtowithdrawalofbloodandother : bodilyfluids,xraysandotherlaboratoryexaminations; & <(` ` hp x (#` ` X<2   c  .3   ` Releasesandinspectionsofmedicalhistoryrecords; p <(` ` hp x (#` ` X<2   d  .3   ` Immunizations; \ <(` ` hp x (#` ` X<2   e  .3   ` Administrationoflawfullyprescribeddrugs;and H f.0 ` Examinationsincluding,butnotlimitedto,thewithdrawalofbloodorotherbody 4 fluidsortissuesforthepurposeofdeterminingthechildsparentage. ` (#` (#   B.` hp x (#` ` XB X?+ ` hp x (#X?HealthcareprovidersrenderingcareortreatmentareadvisedthatpursuanttoK.S.A.38  2217(a)(5), Anyhealthcareproviderwhoingoodfaithrendershospital,medical,surgical,  mentalordentalcareortreatmenttoanychildordisclosesprotectedhealthinformation r authorizedbythissectionshallnotbeliableinanycivilorcriminalactionforfailureto ^ obtainconsentofaparent. J   XB.` hp x (#XBNOTICETOPERSON(S)RECEIVINGCUSTODY: ""  K.S.A.382232(d)requiresthatthepersonreceivingcustodyofthechild(ren)forwardacopyofthis #X" applicationtotheCounty/DistrictAttorneywithoutunnecessarydelay. $D # K.S.A.382232(e)requires,absentacourtordertothecontrary,thechild(ren)mustbereleasedafter &"% 72hours,excludingSaturdays,Sundaysandholidays. '#& ___________________________________    ____________________ x ____________ n*%) ApplicantOfficersSignature   h     Date p      x Time Z+&* PursuanttoK.S.A.382232(f),absentacourtordertothecontrary,theCounty/District_Attorney_Ԁor 2-(, theplacinglawenforcementagencyhastheauthoritytodirectthereleaseofthechild(ren)atany .|)- time.  Child(ren)deliveredto:____________________________________________________________  ______________________________________________________________________________ z ______________________________________________________________________________ f ______________________________________________________________________________ R XXXX@jj&Authority *  K.S.A.382232.  ` @$NotesonUse $    Wheneveralawenforcementofficertakesachildintocustodywithoutacourtorderand   placesthechildasauthorizedbyK.S.A.382232(a),thelawenforcementofficershallcompletean   applicationforcare.Thefacilityorpersontowhomthechildisdeliveredshallhavephysical v  custodyandprovidecareandsupervisionforthechilduponreceiptoftheofficersapplication.The b personorfacilityreceivingthechildshallfurnishacopyoftheapplicationtothecounty/district N attorneywithoutunnecessarydelay.Thelawenforcementofficerisrequiredtoprovidetothe : county/districtattorneyallinformationavailablepertainingtothechild,theparentsorotherpersons & interestedinorlikelytobeinterestedinthechild,andotherinformationrelatingtothedecisionto p takethechildintocustody. \   TheplacementwhichalawenforcementofficerdesignatesforachildpursuanttoK.S.A.38 H 2232shalldischargethechildnotlaterthan72hoursfollowingadmission,excludingSaturdays, 4 Sundaysandlegalholidays,unlessacourthasenteredanorderpertainingtotemporarycustodyor   release.     K.S.A.382232(a)providesthatachildwhoisalleged,butnotyetadjudicated,tobeachild  inneedofcarepursuanttoK.S.A.382202(d)(9)or(d)(10),therunawayprovisions,maybe  deliveredtoajuveniledetentionfacilityorothersecurefacilityif,afterdeliveryofthechildtoa r shelterfacility,thepersoninchargeofthefacilityatthattimeandthelawenforcementofficer ^ determinethatthechildwillnotremainintheshelterfacility.Thechildmaynotbedetainedina J  juveniledetentionfacilityorothersecurefacilityformorethan24hours,excludingSaturdays, 6! Sundaysandlegalholidays.Thestatutedoesnototherwisecontemplateplacementofachildina ""  juveniledetentionfacilityorothersecurefacility,exceptforviolationofavalidcourtorder,as #l! providedinK.S.A.382260,Forms172,173and174. #X"   Intheabsenceofacourtordertothecontrary,thecounty/districtattorneyortheplacinglaw $D # enforcementagencyshallhavetheauthoritytodirectthereleaseofthechildatanytime. %0!$ #XXXXp*#