Sign the consent form.

Program Participants:

Treatment Provider: __________________________________

Probation Officer: _________________________________

Safe Guard: __________________________________

Dates of Participation: __________________________________

Offender Name: __________________________________

Offense: __________________________________

Informed Consent:

My participation in the Safe Guard Program is entirely voluntary, and I may leave the program anytime I wish. I understand that I must complete all of the performance objectives stated on this form in order to be an approved safe guard, and I must complete them to the satisfaction of the Department of Corrections staff responsible for the program. I give consent for a copy of this form to be placed in the Department of Corrections file of the offender on whose behalf I am attending this program.

Signature: ______________________________________

Date: ______________________________________

Witness: ______________________________________ (Treatment Provider)