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  • Good Samaritan Community Services

    FAMILY HOUSEHOLD REGISTRATION FORM
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  • HEAD OF HOUSEHOLD/ADULT PARTICIPANT

    Please provide information on the primary caregiver or adult applying for services.
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  • HOUSEHOLD DEMOGRAPHIC INFORMATION





  • OTHER HOUSEHOLD MEMBERS

    List all individuals, other than yourself,  who live in your household.
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  • PROGRAM ENROLLMENT FORM

    (*Indicates Required Field)
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  • EMERGENCY CONTACTS  

    The following individuals may be contacted in the case of an emergency.
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  • ORIENTATION TO PROGRAM SERVICES

    I acknowledge I have been oriented to program services, either in person or through written communication (letter explaining program services and expectations and/or received a copy of the program handbook), that included program hours and days of operation, program procedures and participant expectations.
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  • RELEASE OF LIABILITY

    I hereby release Good Samaritan Community Services Staff and affiliates from all liabilities that may arise from accidental injury or damage to my or my child’s personal property. This includes, but is not limited to, all claims involving transportation to or from any activities and against any person or organization providing activities.
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