Family Orientation Manual: Appendix D (Sample Visitors Consent Form)

I, ________________________________________________, am an approved visitor for inmate
Visitor's Name (please print)

_______________________________________. I received a copy of the visiting procedures on
Inmate's Name (please print)

_______________. I have read and understand the visiting procedures I have been issued and
Date shall comply with all present and future rules, policies, and procedures.

YOU ARE REQUIRED TO ANSWER THE FOLLOWING QUESTIONS:

1. Are you a current employee of the Department of Corrections? Yes____ No____

2. Are you an ex-employee of the Department of Corrections? Yes____ No____

3. Are you currently a volunteer, contractor, or (student) intern
for the Department of Corrections? Yes____ No____

4. Are you an ex-volunteer, contractor, or (student) intern?
for the Department of Corrections? Yes____ No____

5. Are you currently visiting another inmate? Yes____ No____

If yes, please list their names:

_____________________________________________________________________________

____________________________________________________________________

6. Are you a victim of the inmate you are approved to visit? Yes____ No____

7. Are any of the minor children which you may escort to visiting a
victim of the inmate you wish to visit? Yes____ No____

FALSIFICATION OF ANY INFORMATION SHALL BE GROUNDS FOR DENIAL!

____________________________________________________________________________________
Visitor's Signature Witnessing Officer's Signature Date

Utah State Prison Orientation for Inmate Friends and Family

APPENDIX D - Sample Visitor's Consent Form

FALSIFICATION OF ANY INFORMATION SHALL BE GROUNDS FOR DENIAL!