Form KDOC-0120 "Emergency Shelter - Placement Extension Request" - Kansas

What Is Form KDOC-0120?

This is a legal form that was released by the Kansas Department of Corrections - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2011;
  • The latest edition provided by the Kansas Department of Corrections;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form KDOC-0120 by clicking the link below or browse more documents and templates provided by the Kansas Department of Corrections.

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Download Form KDOC-0120 "Emergency Shelter - Placement Extension Request" - Kansas

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Kansas Department of Corrections (KDOC)
Emergency Shelter - Placement Extension Request
Date of Request:
Youth Name:
Emergency Shelter Name:
Emergency Shelter Extension requests can be made for the following situations. Please select one.
Youth is placed in an Emergency Shelter in the same school district from which they were previously attending and no
alternative placement is available in the district, and the youth will be finishing the school term within 60 days of admission to
the Emergency Shelter and movement of the youth would result in the loss of school credit. (Up to 30 days extension only)
The youth is awaiting an identified placement, which will be available within 45 days of admission to the Emergency
Shelter. (Up to 15 days extension only)
Projected Extension Begin Date:
Projected Extension End Date:
Additional comments/notes:
________________________________________________
Judicial District:
Community Supervision Officer Signature
Date
________________________________________________
Supervisor Signature (Approval)
Date
PLEASE NOTE: Once supervisory approval has been obtained, you may scan and email the Emergency Shelter
Placement Extension Request form to ESExtension@doc.ks.gov. You can also fax the completed form to the attention of
the Contracted Services Manager at 785-296-1412.
________________________________________________
Valid through: _______________
KDOC Signature (Approval)
Date
State of Kansas
Kansas Department of Corrections
Form: KDOC-0120
Revised: May 2011
Kansas Department of Corrections (KDOC)
Emergency Shelter - Placement Extension Request
Date of Request:
Youth Name:
Emergency Shelter Name:
Emergency Shelter Extension requests can be made for the following situations. Please select one.
Youth is placed in an Emergency Shelter in the same school district from which they were previously attending and no
alternative placement is available in the district, and the youth will be finishing the school term within 60 days of admission to
the Emergency Shelter and movement of the youth would result in the loss of school credit. (Up to 30 days extension only)
The youth is awaiting an identified placement, which will be available within 45 days of admission to the Emergency
Shelter. (Up to 15 days extension only)
Projected Extension Begin Date:
Projected Extension End Date:
Additional comments/notes:
________________________________________________
Judicial District:
Community Supervision Officer Signature
Date
________________________________________________
Supervisor Signature (Approval)
Date
PLEASE NOTE: Once supervisory approval has been obtained, you may scan and email the Emergency Shelter
Placement Extension Request form to ESExtension@doc.ks.gov. You can also fax the completed form to the attention of
the Contracted Services Manager at 785-296-1412.
________________________________________________
Valid through: _______________
KDOC Signature (Approval)
Date
State of Kansas
Kansas Department of Corrections
Form: KDOC-0120
Revised: May 2011