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Success By 6 Participant Enrollment Application

Which program are you interested in?

Agency/Contract ID number

Workflow

Enrollment ID No.

Planned Service Frequency

Less than 1x/month

1x/month

2x/month

More than 2x/month

Enrollment start date

Service Start Date

Staff assigned to family

Name of person completing intake

Data-entry staff name and data-entry date

*AUTHORIZATION FOR SERVICE
I have been provided information on the referenced Family Support Services Program and wish to receive services. I understand that data on my child/youth/family will be collected, maintained, and entered into a secure database. The information will be utilized to track services for evaluation purposes and to ensure quality
services are being provided. I hereby authorize my child/youth/family to participate in the program.

Signature

Sign above

Date

Parent/guardian's printed name

Index child/youth name

Authorization for Service must be completed per Index Child/Youth at enrollment and annually

Success By 6 Programs Participant Enrollment Form

Success By 6 Participant Enrollment Application