Reimagine Applicant Information
Youth Living in a single-parent household?
Youth has witnessed or been the victim of family violence?
Youth is homeless?
Youth identifies with LGBTQ+ community?
Youth residing in a household receiving TANF?
Youth Lives with siblings who are gang involved?
Youth is in danger of, or has been previously held back to repeat one or more academic years?
Youth lives with siblings who are involved in the juvenile justice system?
Youth experiencing truancy concerns?
Youth lives with siblings who have dropped out of school?
Youth is reported to have behavior issues?
Youth is reported to be in a gang?
Youth is reported to be the victim of bullying?
Youth is in the DCFS system?
Youth is reported to be the perpetrator of bullying?
Youth is pregnant or parenting?
Parent or Guardian Information
Emergency Contact Information
Physician or Medical Facility Information
AUTHORIZATIONS: I verify that the information on the applicant above is complerte and acurate. I understand that reasonable measures will be taken to safeguard the health and safety of all participants and that I will be notified as possible in the event of an emergency. Therefore, I hereby authorize the staff of LBDNH (paid or volunteer) to take any reasonable action to obtain medical care for the applicant above and absolve them of any liabilityfor such action. I hereby authorize any emergency medical, surgical, diagnostic and hospital care, treatment or procedures deemed immediately necessary or advisable by emergency technician’s, physicians, or hospital my child’s health when I cannot be easily contacted.
