Youth Information
Section 1
Youth under the age of 21
are eligible to apply under this program.
Youth Name:
*
First Name
Last Name
Recipient ID # (RIN):
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Phone Number:
Please enter a valid phone number.
NA
Address of Current Residence:
*
City:
*
State:
*
Zip Code:
*
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Legal Guardian Information
Section 2
Is the youth their own guardian? If YES, skip this section.
*
Yes
No
Legal Guardian Name / Parent Name:
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Mailing Address:
*
City:
*
State:
*
Zip Code:
*
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Authorized Representative Information
Section 3
I am giving permission to Blue Kite Wellness to do the following in my behalf (check all that apply):
*
Submit this request for eligibility determination on my behalf.
Receive information about this request for eligibility determination.
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Youth/Parent/Legal Guardian Attestation and Signatures
Section 4
I understand that HFS will notify me of the outcome of the Pathways to Success eligibility determination review by mail.
*
By checking this box, I request that HFS also email me a copy of the eligibility determination review outcome letter to the following email address:
Email Address
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
Signature:
*
Youth age 18 or emancipated
Parent / Legal Guardian Name
Youth age 18 or emancipated
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Parent/Legal Guardian
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
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