DCS Intake Application & Signatures

Youth Program Application Form

, am the parent/guardian of (Print Child's Name) (Print Parent/Guardian Name) and give consent for my child and or myself to participate in this program. I understand that by signing this agreement, I agree to save and hold harmless and indemnify Diversified Community Services (DCS) the

Print ParentGuardian Name*

Child's Name*

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) or commercial media outlets. I agree that my child or myself may take part in data collection methods (surveys, questionnaires, etc that will assist the program

indetermining 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 Health, Veterans and Community Wellness, Youth and Services Bureau, 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.

Print Name of ParentGuardian*

Signature of ParentGuardian*

Parent Email

19185 Wyoming . Detroit, MI 48221 Phone (248) 798-4048 Fax (248) 721-8360

Youth's Last Name*

Youth's First Name*

Youth's Middle Initial

Date of Birth*

Date

Gender*

Height*

Weight*

Eye Color*

Hair Color*

Race*

Religious Affiliation

School Attending*

Grade*

FatherGuardian Name

Date of Birth

Date

Address City State Zip Code

Phone Number

MotherGuardian Name

Date of Birth

Date

Address City State Zip Code

Phone Number

Stepparent Name if applicable

Date of Birth

Date

Phone Number

Emergency Contact Name

Phone Number

Please enter a valid phone number.

Child Lives With (Mother Father Both Parents Guardian)*

Marital Status (Single, Married, Widowed, LTP)

List Names of Siblings

List Siblings Date of Birth

Siblings Address if different

Names of Nearest Relative

Address

19185 Wyoming . Detroit, MI 48221 Phone (248) 798-4048 . Fax (248) 721-8360

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.

Parent/Guardian Name*

Child's Name

Diversified Community Services to obtain my child's academic records (report cards, progress reports, etc

School Name*

Address

Phone Number

| 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

19185 Wyoming . Detroit, MI 48221 Phone (248) 798-4048 Fax (248) 721-8360

Youth Signature

Parent/Guardian Signature*

Agency Worker Signature

Youth Signature

ParentGuardian Signature*

Agency Worker Signature

Please fax the completed form to the attention of the Court JAC Supervisor at (313) 833-5973

ACADEMIC RECORD RELEASE FORM