Texas Alliance of Boys & Girls Clubs Form 7482 JD, Revised 10/14 24034326 Boys & Girls Clubs of ______Prevention and Early Intervention Registration Form Statewide Youth Services Network (SYSN) Authorization for Service

I have been provided information on the referenced DFPS Prevention and Early Intervention Program and wish for my child/family to receive services. I understand that data on my 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 youth/family to participate in the program.

______Signature Date ______Printed Name of Parent or Guardian Target Child’s Name

REGISTRATION DETAIL and CONTRACTOR INFORMATION  Initial Registration*  Change/Update  Inactive Date ______\ ______\ ______\ ______\ ______\ ______\ ______MM DD YYYY MM DD YYYY MM DD YYYY Name of Person Completing the Form Name of Person Data Entering the Form into the PEIS Database

Family Registration ID Number (PEIS database will generate this number) Date Form was Entered Into the PEIS Database ______\ ______\ ______MM DD YYYY

TARGET CHILD INFORMATION First Name* Middle Name Last Name* Suffix  II  III  IV  JR  SR

Social Security Number Date of Birth* ______\ ______\ ______- ______- ______MM DD YYYY Gender*  Female  Male  Unknown Does the Target Child have a Disability?*  Yes  None/Unknown Race (Check all that apply.)* Ethnicity*  Hispanic Annual Family Income  AM Indian/AK Native  Native Hawaiian/Pacific Islander over $63,000?*  Non-Hispanic  Asian  Unable to Determine  Unable to Determine  Black  White  Yes  No Name of School Participant Attends* Type of School Attended  Junior High School  Elementary  Senior High School  Middle School  Other Education Level of Child (Check the current or highest grade completed.)* Marital Status  Pre-K/Kinder  Child N/A  1st  6th  11th  Married  2nd  7th  12th  Divorced  3rd  8th  Did Not Graduate  Separated  4th  9th  Graduate H.S./GED  Single, Never Married  5th  10th  Unknown  Unknown  Widowed County of Residence* Does the Target Child Live in a Colonia?  Yes  No If yes, print the name of the Colonia: ______Address Type  Primary  Secondary Home Address Details* ______(Street) ______\ ______\ ______(City) (State) (Zip) Phone Type Phone Number* Primary E-mail Address

 Home  Work  Other ( ______) ______- ______* Information with an asterisk is required. I have reviewed this child’s eligibility regarding risk factors per RFP section 2.5.4 AND made a good faith determination that the child is not involved with Juvenile Probation or adjudicated. Signature of Staff Member:

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