DCS/Urby Ed Application

Parent/Agency Agreement Youth Application Form

I, am the parent/guardian of and give consent for my child and/or myself to participate in all of Diversified Community Services programs. I understand that by signing this agreement, I agree to save and hold harmless and indemnify Diversified Community Services (DCS) the extent permitted by the law from all liability, loss, cost claim or damage whatsoever which may be imposed upon or incurred by said parties because of the participation of the minor in the program and release said parties in this regard on behalf of both the minor and the parents or legal guardians as well. I also grant permission for the use of images and the voice of the student and or parent while the student and or parent is involved in program activities, for promotion of Diversified Community Services (DCS), whether produced by Diversified Community Services (DCS), third party programs, or other third-party media outlets. I agree that my child or myself may take part in data collection methods (surveys, questionnaires, etc that will assist the program in determining if my child or myself was satisfied with services and if set expectations and outcomes of the program were met. Further, I understand that Diversified Community Services (DCS) programming is provided at low or no cost through grantor agencies such as the Michigan Department of Health and Human Services, Wayne County Juvenile and Youth Services, and other private and foundation funding and my child's participation in the program may be funded through one or several of these funding sources.

Parent/Guardian Name

Child's Name

Signature of ParentGuardian

Print Name of ParentGuardian

ParentGuardian Email

example@example.com

Name

Youth First NameYouth Last Name

Youth Date of Birth

Date

Gender

Height

Weight

Eye Color

Hair Color

Race

Religious Affiliation

School Attending

Grade

Mother's Name

Mother Date of Birth

Date

Phone Number

Format: (000) 000-0000.

Address

Street Address Line 2

CityState

Zip

Father's Name

Father Date of Birth

Date

Phone Number

Format: (000) 000-0000.

Address

Street Address Line 2

CityState

Zip

Medical Problems Restrictions andor Allergies

Emergency Contact Person

Relationship

Phone Number

Format: (000) 000-0000.

Child Lives with (Mother, Father, Both Parents, Guardian, Stepparent)

Additional Demographic Information

Marital Status Single Married Widowed LTP

Name of Sibling

Sibling DOB

Sibling Address if different

Name of Sibling

Sibling DOB

Sibling Address if different

Name of Sibling

Sibling DOB

Sibling Address if different

Name of Sibling

Sibling DOB

Sibling Address if different

One of our primary program goals is to increase student's academic performance. Academic records are used for program evaluation purposes only. Diversified Community Services has an obligation to keep your personal information, identifying information, and records confidential.

I, parent/guardian of authorize Diversified Community Services to obtain my child's academic records (report cards, progress reports, etc.) from:

Parent/Guardian Name

Child's Name

School Name

School Address

Phone Number

Format: (000) 000-0000.

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.

Signature of ParentGuardian

Youth Signature

ParentGuardian Signature

Agency Worker Signature

DIVERSIFIED COMMUNITY SERVICES