OVERNIGHT PASS APPLICATION

I, __________________________________________________________, am requesting an overnight pass for the following persons:
                              (Client Name)
__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

 to stay out of the Shelter from ___________to __________ for the following reason(s) ______________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

If granted, residency during this pass will be with:

Family information:

Name __________________________________________

Address ________________________________________

Borough _________________ Zip ___________________

Relationship _____________________________________

Phone (   ) ______________________________________

I understand that bed space cannot be left vacant while there are homeless persons who are eligible and in need of it.  For this reason, I understand that if I or my family do not return to the shelter before curfew (Time:______)  on _____________, I or my family may lose the bed space and will not be able to re-enter the shelter without a brand new Referral from E.A.U. or I.M.

                                           	Signed: ___________________________________
                                                   	                  Client's Signature

SHELTER'S DECISION

A review of the family's Case Record was conducted.  On the basis of this review it is felt that the request for an Over-night Pass should be:

Approved    Disapproved because:_________________________________________________________

_________________________________________________________________________________________

Case Worker Signature:  _________________________________	Date:  _________________________

Supervisor/Director  Signature:   ___________________________  	Date:  _________________________
                                        	
Copy:	Administrative file
	Resident Copy
          	Resident file