Matrix Youth Assistance Program

Matrix Youth Assistance Program

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

First NameLast Name
School*
Current Grade*
Youth Date of Birth*

MonthDayYear
Date
Youth Gender*

MaleFemale
Youth Race*

Black/African AmericanWhite/CaucasianOther
Youth Height (ex. 5'2)*
Youth Weight (lbs)*
Hair Color*
Eye Color*
Program of Interest*

Tutoring (Grades 4th-12th): Mon-Thurs 4-5pmYoga-Black Girl Yoga (Ages 7-17): Mon 5:30-7:30pmScience Exploration- Mad Science (Ages 7-13): Wed 4:30-5:45pmKeys to Life- Life & Social Skills (Ages 7-17): Thurs 5-6pmFULL, WAITLIST ONLY Matrix Basketball Life Skills Program (Ages 7-17)FULL, WAITLIST ONLY Matrix-DTT Boxing Foundation (Ages 7-17)
Parent/Guardian Name*

First NameLast Name
Parent Date of Birth*

MonthDayYear
Date
Address (Wayne County address required)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Email*
example@example.com
Phone Number*
Please enter a valid phone number.
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*

Clear
Youth Signature*

Clear
Should be Empty: