Professional Documents
Culture Documents
0829
Plainfield, IL 60586 familymatters@familymattersfoundation.com
Youth’s Name:____________________________________________________
Parent/Guardian Name:_____________________________________________
Emergency Contacts:
1. I have voluntarily my child/ward (name above) to participate in one or more youth programs offered by Family Matters
Foundation, INC; (Youth Empowerment For Success)
2. I agree to allow Family Matters Foundation staff to use their reasonable judgment act on my behalf in case any medical or
other emergency (including, but not limited to, applying first aid, contacting or seeking treatment from a health care
provider) requires such action while my child/ward is participating in the program.
3. I agree that any expenses that may be incurred under item 2 will be the sole responsibility of the child/ward family.
Parent/Guardian Signature__________________________________________________________Date_____________________
______________________________________________________________________________________
Y.E.S. program, the place where young people deserve to feel and can be safe. It really is a safe place.
Copyright 2007 Gregory H. Thomas
2714 Adobe Drive Phone: 312.772.0829
Plainfield, IL 60586 familymatters@familymattersfoundation.com
Intake Number:____________________________________________________
Educational Needs:_________________________________________________
Career Training:___________________________________________________
Employment Assistance:_____________________________________________
Recreation/Activities:________________________________________________
Prevention:_________________________________________________________
Assigned Counselor:_________________________________________________
______________________________________________________________________________________
Y.E.S. program, the place where young people deserve to feel and can be safe. It really is a safe place.
Copyright 2007 Gregory H. Thomas