Juvenile Services Program Application - Wichita and Affiliated Tribes

Company

This field is for validation purposes and should be left unchanged.

Applicant Information

Youth Name*

First Last

CDIB Card #

Sex

Date of Birth*

Physical Address*

Street Address Address Line 2 City State ZIP Code

Finding Directions (if necessary)

Mailing address same as physical address?*

Yes

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Last School Attended*

Grade Completed*

Medical Card #

Card Issue Date

Anadarko Indian Clinic Chart #

Lawton Indian Clinic Chart #

List any current medical conditions/medications:

Legal Custodian/Guardian Name*

First Last

Tribe of Enrollment

Relationship to Youth*

Phone*

Parents are:

Married

Single parent

Divorced

Separated

Deceased

Biological Mother Name*

First Last

Date of Birth

Phone

Address

Street Address Address Line 2 City State ZIP Code

Place of Employment

Biological Father's Name*

First Last

Date

Phone

Address

Street Address Address Line 2 City State ZIP Code

Place of Employment

Siblings residing in the home

Name

Sex

DOB

Referred by*

Briefly describe reason(s) for request for services*

Financial Assistance

Family profile

Name

DOB

Sex

Relation to client

List all members of household, including youth.

Forms of income

Income Source

Amount (include whether weekly or monthly)

Includes child support, veteran assistance, public assistance (TANF), unemployment, disability, or social security benefits. Income will not be counted against you.

Attention: Financial assistance through this program is based on federal poverty guidelines. Any person who makes a false statement or misrepresentation on this form shall be subject to penalties which may include termination of services for the above named youth.

By signing & submitting this form, you agree that all the above information is true and accurate. You also agree to notify this department of any changes to your family income.

Parent/Guardian Consent

I do hereby authorize the Wichita & Affiliated Tribes Services Program (JSP) to provide services to my minor child. By signing this consent form, I acknowledge the following:

The JSP services available have been explained to me in a manner I understand.
JSP services are voluntary and there is no cost for any of the services provided.
JSP shall not be responsible for payment of any court-related fines relating to my child.
Recommendations made on behalf of my child either through the JSP or an affiliated or contracted agent thereof, will be in the best interest(s) of my child.
Through the signing of a proper release form, I give permission and authorization to obtain any information needed, from any agency or entity they deem necessary, in order to provide services to my child.
All information relating to myself or my child received through JSP shall be held confidential.
I can withdraw my child from this program at any time; further, my lack of participation and cooperation, as well as that of my child, will give this program just reason to deem as my withdrawal.

Signature of Youth*

Signature of Parent*

Date