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YOUTH
APPLICATION
First Name
Middle Name
Last Name
Birthday
Gender
Race/Ethnicity
Home Address
City
State
Zip
Non-Parental / Non-Guardian Emergency Contacts
Name
Phone
Relationship to Child
Name
Phone
Relationship to Child
School Information
Child's School
Grade
Teacher
Is child currently enrolled in any special programs at school?
Yes
No
Special School Programs
Medical Information
Is your child currently taking any medication?
Yes
No
Medications
What medical problem(s) does this medication treat?
Please list all other medical problems, allergies or special health concerns:
Home Environment
Type
Comment / Notes
Is it a safe environment?
Comment / Notes
Pets in Home?
Comment / Notes
Firearms in House?
Comment / Notes
Parent / Guardian / Caregiver
With whom does the child currently live (caregiver)
Who is the child’s legal guardian?
Caregiver relationship to child?
Parent
Guardian
Other
Other Note
Caregiver Marital Status
Single
Married
Separated
Divorced
Widowed
Add answer here
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