<p> 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</p><p>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.</p><p>______Signature Date ______Printed Name of Parent or Guardian Target Child’s Name</p><p>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</p><p>Family Registration ID Number (PEIS database will generate this number) Date Form was Entered Into the PEIS Database ______\ ______\ ______MM DD YYYY </p><p>TARGET CHILD INFORMATION First Name* Middle Name Last Name* Suffix  II  III  IV  JR  SR </p><p>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</p><p> 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:</p><p>1</p>