Acknowledgement of Items Received

I have received the following items from the program. I accept full responsibility for washing and
returning them prior to my departure. I understand that failure to return them will result in my financial
obligation for their replacement.
Quantity

Item

Description

Pillow
Pillow Case
Sheets
Bath Towels
Face Cloths
Blankets
Comforters
OTHER:

Resident Signature: ____________________________________________

Date__________

Staff Signature: _______________________________________________

Date__________

Formatted By:

FAMILY SHELTER MODEL RECORD TEAM

Sponsored by the Department of Public Health, Bureau of Substance Abuse Services

Facilitated by The Quality Improvement Collaborative