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YOUTH APPLICATION

Non-Parental / Non-Guardian Emergency Contacts

School Information

Is child currently enrolled in any special programs at school?

Medical Information

Is your child currently taking any medication?

Home Environment

Parent / Guardian / Caregiver

Caregiver relationship to child?
Caregiver Marital Status

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127 W. Wesley St.
Jackson, MI 49201

Phone: 517-784-7181
Fax: 517-796-9004
Office Hours:

M-Th 8:30 - 4:00 

Fri: 8:30 - 12:00

STAY UP TO DATE!

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