Child(ren)’s Name:
Child(ren)’s Date of Birth:
Date:
Official Notice of Temporary Placement of a Child
This letter serves as notice that the above child(ren) has been placed on a Temporary Alternative
Placement Agreement for up to 90 days beginning	and ending on
(unless earlier terminated) with the following Temporary Placement Provider:
Name:
Address:
Relationship to child:
E-mail:
Phone:
This Temporary Placement Provider has the authority under Missouri law to make the day-to-day decisions for the care of the child for the duration of the agreement, including the authority to make educational and medical decisions for the child. Individuals and institutions, including schools and medical care providers, acting upon the authority of this notice shall be immune from liability as set forth in this letter as provided in §210.123.5(3) RSMo. If the placement is extended beyond its expiration date you will be provided with a new notice. In addition, you may be asked to participate in Team Decision Making meetings to assist the child’s parent(s), legal guardian(s), Temporary Placement Provider(s) and the Children’s Division to make decisions regarding the best interests of the child. If you have questions or concerns about this Notice or the welfare of the child(ren) you may contact the Children’s Division.
Sincerely,
Children’s Division
Phone Number	Email Address