Matrix Youth Assistance Program

Matrix Youth Assistance Program

Located at 13560 E. McNichols, Detroit, MI 48205.
Youth Information
Youth Name

First NameLast Name
Youth Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Youth Age
Youth must be ages 7 through 17.
Most Recent School Attended
Grade
Youth Sex
Youth Gender
Youth Race

Other
Youth Address (Wayne County address required)

Street Address

Street Address Line 2

CityState

Zip Code
Youth Height (ex. 5'2)
Enter best estimate if unknown
Youth Weight (lbs)
Enter best estimate if unknown
Youth Hair Color
Youth Eye Color
Parent or Guardian Information
Parent/Guardian Name

First NameLast Name
Relationship to Youth
Parent/Guardian Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Address (Wayne County address required)

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact

Please provide an emergency contact that is not the parent/guardian already listed.
Emergency Contact Name

First NameLast Name
Relationship to Youth
Emergency Contact Address

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Program Selection

Please note that programs listed are dependent on the age of the youth.
Select the programs for enrollment
Please choose between Yoga and DJing.

You have selected two programs that overlap (Hey Black Girl Yoga and Intro to DJing). Please select only one of these programs to eliminate the schedule conflict.
Please choose between DJing and Boxing.

You have selected two programs that overlap (Intro to DJing and Boxing WAITLIST). Please select only one of these programs to eliminate the schedule conflict.
Please choose between Mad Science and Basketball.

You have selected two programs that overlap (Mad Science and Matrix Basketball). Please select only one of these programs to eliminate the schedule conflict.
Programs of Interest
Additional Information
What tools would help your child be successful at home or in school?
What goals should your child work towards while in this program?
What are your child's strengths at home & in school?
What are your child's academic strengths and areas for improvement?
Does your child have a special education plan, individual education plan (IEP), or 504 plan as part of their school's education?
At school, is your family eligible to receive free lunch?
Most Recent Report Card or Progress Report

Cancelof
How did you hear about Matrix Human Services?
By signing below, you acknowledge that your child is expected to attend all scheduled workshops. In the event of any absence—scheduled or unscheduled—you are required to notify us via email at yapservices@matrixhs.org or by texting 313-938-0187. Youth that exceed two absences without written notification will be automatically disenrolled from the program.

Please note, youth and parent signatures are required to receive services.
Parent Signature
Youth Signature
Should be Empty:

Matrix Youth Assistance Program

Youth Information

Parent or Guardian Information

Emergency Contact

Program Selection

Please choose between Yoga and DJing.

Please choose between DJing and Boxing.

Please choose between Mad Science and Basketball.

Additional Information