YBL: Group Services

Group Services Form

Please read all of the questions and guidelines carefully, taking time to answer fully. Note that some questions will have an "ex:" (example) answer to help guide you. If you need further assistance in completing the form, please ask a staff supervisor.
Case Manager/ Staff Name*

First NameLast Name
Case Manager/ Your Email*
Please enter email to receive a receipt of what's submitted.
Services can be "* Qualifying" or "Non-Qualifying". Only services that are "* Qualifying", extend the exit date of participants. Qualifying services are denoted by "*". Enter up to 6 services.
Select Service 1:*
Start Date of Service*

MonthDayYear
Date
End Date of Service*

MonthDayYear
Date
Student Names who participated in activity:*
Should be Empty:

Group Services Form