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2714 Adobe Drive Phone: 312.772.

0829
Plainfield, IL 60586 familymatters@familymattersfoundation.com

FAMILY MATTERS FOUNDATIONS, INC.


Family Matters Foundation INC;
Youth Empowerment For Success Program
Youth Registration Form.

Youth’s Name:____________________________________________________

Parent/Guardian Name:_____________________________________________

Address:______________________________ City, State, Zip Code:_______________________________________

Home Phone # Work/Cell # E-mail Address

School Attending School ID Grade

Emergency Contacts:

Name Phone Number Relationship

Name Phone Number Relationship

Persons Authorized To Pick Up Child:______________________________________________________________________


Must have ID At Pick Up.

My Child Has Permission To Walk Home Along: YES____________ NO______________

Consent To Participate In Youth Programs


I grant permission for my child/ward:
. To participate in all activities of the youth program
. To participate in program field tips under proper supervision
. To ride in agency and personal vehicles of authorized F.M.F. staff for program activities
. To be interviewed or photographed and to take part in promotional and public relations activities
. For F.M.F. youth staff to communicate with school staff about my child, and obtain information on my child’s/ward’s school records

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

FAMILY MATTERS FOUNDATIONS, INC.


Family Matters Foundation INC;
Youth Empowerment For Success Program
Youth Registration Form.

Intake Number:____________________________________________________

Educational Needs:_________________________________________________

Career Training:___________________________________________________

Employment Assistance:_____________________________________________

Life Skills Training:_________________________________________________

Recreation/Activities:________________________________________________

Medical Issues: Allergies/Health/Diet concerns/Disabilities:_________________________________________________________


If your child/ward needs prescription medication during program hours, a separate medication permission form must be completed

Intervention: YES____ OR NO____

Prevention:_________________________________________________________

Assigned Counselor:_________________________________________________

Assessment/Intake Director Signature:___________________________________________


Date______________

Case Management Director Signature:____________________________________________


Date_______________

Executive Director 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

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