Sex Offender Informed Consent for Visitation of Minors

Offender’s Information
Offender’s name: IDOC#:
Conviction history:
Age of victim(s):

Person who has Legal Parental Rights
Statement of Understanding and Agreement
My Minor Child’s Name Date of Birth My Minor Child’s Name Date of Birth

My Current Home Address:
Street City State Zip
My Current Phone Numbers:
Home Cell Other
In preparation of ‘s (hereinafter referred to as ‘the offender’) contact with my minor child/children, I have been informed of the offender’s conviction history and the age of
the victim(s).
I understand that the offender is in a treatment program and has earned the privilege of having contact with my minor child/children. I also understand that although the offender is
involved in treatment, it is possible for the offender to reoffend.
I agree to help the offender avoid any physical contact with my minor child/children. I also agree that under no circumstances will my minor child/children ever be left alone with the
offender (this includes being left alone in an automobile or room).
Based on the information given to me about the offender’s conviction history and the age(s) of the victim(s), I hereby give my informed consent for my minor child/children to have contact
with the offender. I understand that a copy of this form will be provided to the offender’s supervising probation and parole officer (PPO).
Furthermore, I understand that this form does not give or imply permission for the offender to have contact (supervised or unsupervised) with any other minors. I also understand that
any contact the offender has with minors, including my minor child/children, must be approved by the offender’s supervising PPO and treatment provider.

Parent’s Printed Name

Parent’s Signature Date
IDOC Approval
Approved  Denied 
PPO’s Printed Name

PPO’s Signature Date
Approved  Denied 
District Manager’s (or Designee’s) Printed Name

District Manager’s (or Designee’s) Signature Date