OPENING DOORS FOR KIDS, INC.  (YOUTH)

1256 FRANKLIN AVE

WILKINSBURG, PA 15221

(800)618-8582 Office (412) 223-4350 Fax

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Today’s Date:


Last Name_________________________  First Name________________________________


Street address______________________  City_____________  State_____ Zip________  


Daytime PhoneNumber__________________EveningP honeNumber_________________


D.O.B_____________ Age______ Grade_______  School_____________________________


Parent/Guardian Last Name___________________  First Name______________________


Parent/Guardian Telephone Number_____________ Work Number___________________


PARENT/GUARDIAN CONSENT


Does the applicant have any medical problems that require special attention? Y N

If yes, please provide details:___________________________________________________


The above information is true to the best of my knowledge. I permit the above applicant to participate in meetings, events, workshops, and other activities that strictly pertain to the scope of tasks, duties, and activities as outlined in the bylaws of Opening Doors for Youth & Families, Inc. I hereby authorize and consent to participation in interviews, the use of quotes, and the taking of photographs, movies, or video and audio recording of the above applicant. I also grant the right to edit, use, and reuse said products for non-profit educational purposes including print and digital media outlets. I also hereby release Opening Doors for Youth & Families, Inc. and it’s agents from all claims, demands, and liabilities in connection with the above.



Parent/ Guardian Signature:__________________________ Print Name:_________________________

Date:_______________________

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www.openingdoorsforyouthfamiliesinc.com openingdoorsforyandf@gmail.com


Today’s Date

CLIENT REGISTRATION FORM ____/___/___

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Legal Name:________________________________________________________

Preferred Name/ Nickname:___________________________________________

Birth Date:______________ Are you the individual responsible for all bills and insurance? Y N

Marital Status: ()Single()Partnered()Married()Divorced()Separated()Widowed()Other

Street Address:____________________________City_________ State______ Zip________

Mobile Cell:(         ) __________ Home: (       ) __________ Email:_________________

Best way to contact me (check all that apply): () Phone()Email()U.S Mail

Gender: () M () F Social Security Number: _ _ _-_ _-_ _ _ _

Occupation:___________________________ Employer______________________________

Work Phone_____________________

Emergency Contact:____________________ Phone(         )___________________________


PAYMENT

Legal Name of Person Responsible for Bill     () Same as above

Relationship to Client if client is not responsible party______________________________

Birth Date (if client is not responsible party)_______/_______/_______

Social Security Number: _ _ _-_ _-_ _ _ _

Street Address: (if different)______________________City________ State______ Zip_____

Home Phone: (          ) _________________ Cell______________ Work_________________


INCOME

Annual Income:$_________ Household Annual income:$_________

Number of adults in household): ______ Number of children in household (under 18)____



DISCLAIMER STATEMENT

I authorize Opening Doors for Youth & Families, Inc. to submit claims if needed to my insurance carrier and to release any medical information necessary to process all claims. I authorize payment for any service rendered to Opening Doors for Youth & Families, Inc. for all services provided until further notified for this account. I agree that I am financially responsible for any co-pay and self pay balance at the time of service, and any balance that may be due after the claims have been submitted for payment.


Print Name           Signature Date


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