FORM 6
FAMILY VISITATION LIST AND PARENT INFORMATION GUIDE ACKNOWLEDGMENT
Youth Last Name
Youth First Name
County / Placing Agency
Please list those BIOLOGICAL RELATIVES or GUARDIANS permitted visitation and his/her relationship to your child.
Keep in mind that visitation cannot begin until this form is returned and only four (4) people are permitted to visit
at one time.
NAME
RELATIONSHIP
As the parent / guardian of the above-referenced child, I acknowledge by my signature below I have received and reviewed George
Junior Republic’s Parent Information Guide and understand the Child Rights and Youth and Family Grievance policies.
Parent / Guardian Signature
Date
Agency Representative Signature
Date
233 George Junior Road  P.O. Box 1058  Grove City, Pennsylvania 16127  724-458-9330 Ext. 2100  Fax: 724-458-8401