CHIP Program

RISE UP- YOUTH DEVELOPMENT GROUP

Please fill out the Bottom Referral for Youth
This is a 14-week youth group for boys and girls ages 13–17. Participants will meet a minimum of twice a week. Sessions will take place at participating Gyms or Community Parks in the Area.

This is an open group, and it’s important for youth to attend as many sessions as possible. The total cost is $2,900:

Includes:

- 2 hours a week of group physical exercise (Self Defense Driven)
- 1 hour a week of social development talk group
- 14 weeks
- Social events, materials, access to clinical team all included.

Resource Information
Case Manager*

First NameLast Name
CM Phone Number*

Area CodePhone Number
Email*
example@example.com
Case Manager Supervisor*

First NameLast Name
CM Supervisor Email*
example@example.com
Client ID #*

Youth information
Participant full name*

First NameLast Name
Date of Birth*

MonthDayYear
Age*
Mobile Phone (If Applicable)

Area CodePhone Number
E-mail (If Applicable)
example@example.com
Participant address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Current School*
School Year*
Information that we should know *

Parent/Guardians Contact Information
Guardians name*

First NameLast Name
Guardians title (i.e. Mother, Father, etc.)*
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Email
example@example.com
Guardians name (if another has been identified)

First NameLast Name
Guardians title (i.e. Mother, Father, etc.)
Phone Number

Area CodePhone Number
Should be Empty: