LEGACY LANDING OVERNIGHT REQUEST
FORM

Resident Name: Client first nameClient last name

Date Request Submitted: Date

Requested Overnight Date(s): Text field

Destination Address (Where You Will Be Staying): Text field

City: Text field

State: Text field

Zip: Text field

Person Responsible for Residence (if applicable):Text field

Accountability Contact Name:Text field

Relationship to Resident:Text field

Accountability Phone Number:Phone field

Purpose of Overnight Request:

Paragraph

Expected Departure Date/Time:DateTime

Expected Return Date/Time:DateTime

Resident Acknowledgment

I understand that:
● Overnight requests must be submitted at least 24 hours in advance.
● All overnight requests must be turned in no later than 7:00 PM the day before approval is needed.
● Approval is not guaranteed and is subject to staff review.
● I must provide the exact address where I will be staying overnight.
● I must provide a valid accountability contact who can verify my whereabouts if needed.
● Failure to return as scheduled or provide accurate information may result in disciplinary action and/or loss of overnight privileges.

Resident Signature:

Signature

Date: Date

Staff Use Only

Approved:

Radio buttons

Approved By: Text field

Date:Date

Comments:

Paragraph