SOP 214.04-att-1: Participation Agreement

SOP 214.04
Attachment 1

02/20/25
Page 1 of 2

Evidence Based Prison
OFFENDER PARTICIPATION AGREEMENT

I, ________________________________understand that there are a number of rules and
expectations which I must respect as a participant in the Evidence Based Program. By
signing this agreement, I acknowledge my awareness and understanding of the following:

1. I understand that I was referred to this program. I also understand that I am
showing a willingness to participate in this program to make changes in my life.

2. I understand that this is a 2-year program, and I am committing to actively
participate during this time.

3. I agree to promptly attend all scheduled sessions unless given an excused absence
from staff.

I also understand that the program staff and/or volunteers have the discretion to
determine if my missing a session was legitimate. I understand that if my progress
in the program is affected by excessive absences I may be terminated from the
program and not receive a certificate of program completion.

4. I understand that the personal information discussed in the groups is confidential
and I agree to respect this confidentiality by not discussing the information outside
the group. However, I also understand that if I say anything that could show I plan
to harm myself, someone else or the safety of the prison, my counselor, facilitator, or
other staff will report the information.

5. I understand that I will be discharged from the program if I violate any of the
following:

- Acts of physical violence, possession of weapons, gang-related activity,

- Escape planning, use and/or possession of alcohol or any illicit drugs,

and any act, which puts at risk the program, program participants,
staff, volunteers, or the institution.

- Possession of a cell phone

6. I understand the program will support and follow all institutional rules and
regulations outlined in the inmate handbook. I agree to follow all institutional and
program rules and procedures.

7. I understand that during the time I am an active participant in this program I will
be housed at the Evidence Based Prison.

8. At all times I will conduct myself with respect for each participant, staff, and
volunteer.

Retention Schedule: Upon completion this form shall be maintained in offender’s file for two (2) years or if program
completion occurs prior to two (2) years, it may be removed.

SOP 214.04
Attachment 1

02/20/25
Page 1 of 2

9. I am to always keep myself and the dormitory inspection ready.

10. I understand I may be discharged for lack of progress toward goals and/or
consistent violation of rules and procedures.

11. I understand that I will receive a Certificate of Completion if I satisfactorily meet all
requirements of the program.

THE ABOVE INFORMATION HAS BEEN EXPLAINED TO ME AND I HAVE
RECEIVED A COPY OF THE PROGRAM RULES.

|Printed Name of
Offender|Col2|GDC
Number|Col4|
|---|---|---|---|
|Participant
Shirts Issued|Date: ____________________
Quantity: ________________
(should be 3)|Participant
Shirts
Returned|Date: ____________
Quantity: ________
(should be 3)|
|Signature of
Offender||
Date||
|Offender Agrees to participate Offender Refused to participate|Offender Agrees to participate Offender Refused to participate|Offender Agrees to participate Offender Refused to participate|Offender Agrees to participate Offender Refused to participate|
|Printed Name of
GDC Staff||
Facility||
|Signature of
GDC Staff||
Date||
|Status|Approved
Denied|Anticipated
Start Date||
|GDC ONLY COMPLETION FOR PROGRAM DISMISSAL|GDC ONLY COMPLETION FOR PROGRAM DISMISSAL|GDC ONLY COMPLETION FOR PROGRAM DISMISSAL|GDC ONLY COMPLETION FOR PROGRAM DISMISSAL|
|Offender Dismissal from program effective date:|Offender Dismissal from program effective date:|Offender Dismissal from program effective date:|Offender Dismissal from program effective date:|
|Justification for program dismissal
|Justification for program dismissal
|Justification for program dismissal
|Justification for program dismissal
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|Offender is eligible to participate date:|Offender is eligible to participate date:|Offender is eligible to participate date:|Offender is eligible to participate date:|
|GDC Staff (printed name & title):|GDC Staff (printed name & title):|GDC Staff (printed name & title):|GDC Staff (printed name & title):|
|||||

Retention Schedule: Upon completion this form shall be maintained in offender’s file for two (2) years or if program
completion occurs prior to two (2) years, it may be removed.