Proof of Identity – Youth Identity Access Program Intake Form

Proof of Identity – Youth Identity Access Program Intake Form

Complete this form to access support for obtaining your identification documents and participate in the program.
Participant Information
Full Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Date
Age
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP Code
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Parent/Guardian Signature
Referral Information
How did you hear about the program?

Other
Referral Organization Name
Referral Contact Person

First NameMiddle NameLast Name
Referral Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Document Support Needed
State ID

Other
Please explain your current situation or what support you need.
Transportation & Participation
I understand transportation may be provided for scheduled trips.
I understand all participants are expected to behave respectfully during transportation and program activities.
I understand completion of this form does not guarantee immediate document approval through outside agencies.
I opt-in to recieve text and email notifications
I hearby grant Be The Proof Foundation permission to use my child's / children's likeness in photos or videos for any, including web-based, publications without payment.
I hearby grant Be The Proof Foundation permission to use my likeness in photos or videos for any, including web-based, publications without payment.
Signatures
Participant Signature
Date Signed

MonthDayYear
Date
Parent/Guardian Signature
Should be Empty:

Proof of Identity – Youth Identity Access Program Intake Form

Participant Information

Parent/Guardian Information

Referral Information

Document Support Needed

Transportation & Participation

Signatures