Client Intake Form : Take A Break : Youth Development Programs : Programs : YWCA of Lincoln

Client Intake Form

I heard about Take a Break from:

Friend
Event
Flyer
Agency
Other

To be completed by Guardian/Caregiver

Contact Information

First Name

First Name *

Last Name *

Address

Country

Address Line 1 *

Address Line 2 *

City *

State/Province *

Postal Code *

Phone Number (Required)

Work Phone Number

ext Extension

E-mail Address (Required)

Ethnicity

Hispanic or Latino
Non-Hispanic or Latino

Race

White/Caucasian
Black or African American
American Indian or Alaska Native
Middle Eastern
Asian
Native Hawaiian or Other Pacific Islander
Multi-Racial
Other

Financial Bracket (Annual Income - Household)

Unemployed
Estimate $ amount below

Dollar Amount

Weekly
Bi-Weekly
Monthly
Yearly

Number in Household (Required)

Does your family qualify for the free or reduced lunch program?

Date Of Birth (Required)

Age (Required)

Gender

Female
Male
Prefer not to answer

Child #1

Child Name

First Name *

Last Name *

Date of Birth (Required)

Age (Required)

Gender

Female
Male
Prefer not to answer

Biological Child
Temporary Custody
State Ward
Foster Child
Foster Grand Child
Adopted

Respite Subsidy

Ethnicity

Hispanic or Latino
Not Hispanic or Latino

Race

White/Caucasian
Black or African American
American Indian or Alaska Native
Asian
Middle Eastern
Native Hawaiian or Other Pacific Islander
Multi-Racial
Other

Does your child have any of the following special needs?

Please explain any assistance your child will need while they are here.

Does your child have any food allergies or intolerances or are there foods they CANNOT have?

If yes, please explain

Are there any special discipline guidelines?

If yes, please explain

Are there any cultural or religious beliefs that you would like to make us aware of?

If yes, please explain

Is there any additional information you would like us to know about your child?

Child #2

Child Name

First Name

Last Name

Date of Birth

Age

Gender

Female
Male
Prefer not to answer

Biological Child
Temporary Custody
State Ward
Foster Child
Foster Grand Child
Adopted

Respite Subsidy

Ethnicity

Hispanic or Latino
Not Hispanic or Latino

Race

White/Caucasian
Black or African American
American Indian or Alaska Native
Asian
Middle Eastern
Native Hawaiian or Other Pacific Islander
Multi-Racial
Other

Does your child have any of the following special needs?

Please explain any assistance your child will need while they are here

Does your child have any food allergies or intolerances or are there foods he/she CANNOT have?

If yes, please explain

Are there any special discipline guidelines?

If yes, please explain

Are there any cultural or religious beliefs that you would like to make us aware of?

If yes, please explain

Is there any additional information you would like us to know about your child

Child #3

First Name

Last Name

Date of Birth

Age

Gender

Female
Male
Prefer not to answer

Biological Child
Temporary Custody
State Ward
Foster Child
Foster Grand Child
Adopted

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Respite Subsidy

Ethnicity

Hispanic or Latino
Not Hispanic or Latino

Race

White/Caucasian
Black or African American
American Indian or Alaska Native
Asian
Middle Eastern
Native Hawaiian or Other Pacific Islander
Multi-Racial
Other

Does your child have any of the following special needs?

Please explain any assistance your child will need while they are here

Does your child have any food allergies or intolerances or are there foods he/she CANNOT have?

If yes, please explain

Are there any special discipline guidelines?

If yes, please explain

Are there any cultural or religious beliefs that you would like to make us aware of?

If yes, please explain

Is there any additional information you would like us to know about your child?

Child #4

Child Name

First Name

Last Name

Date of Birth

Age

Gender

Female
Male
Prefer not to answer

Biological Child
Temporary Custody
State Ward
Foster Child
Foster Grand Child
Adopted

Respite Subsidy

Ethnicity

Hispanic or Latino
Not Hispanic or Latino

Race

White/Caucasian
Black or African American
American Indian or Alaska Native
Asian
Middle Eastern
Native Hawaiian or Other Pacific Islander
Multi-Racial
Other

Does your child have any of the following special needs?

Please explain any assistance your child will need while they are here

Does your child have any food allergies or intolerances or are there foods he/she CANNOT have?

If yes, please explain

Are there any special discipline guidelines?

If yes, please explain

Are there any cultural or religious beliefs that you would like to make us aware of?

If yes, please explain

Is there any additional information you would like us to know about your child?

Child #5

Child Name

First Name

Last Name

Date of Birth

Age

Gender

Female
Male
Prefer not to answer

Biological Child
Temporary Custody
State Ward
Foster Child
Foster Grand Child
Adopted

Respite Subsidy

Ethnicity

Hispanic or Latino
Not Hispanic or Latino

Race

White/Caucasian
Black or African American
American Indian or Alaska Native
Asian
Middle Eastern
Native Hawaiian or Other Pacific Islander
Multi-Racial
Other

Does your child have any of the following special needs?

Please explain any assistance your child will need while they are here

Does your child have any food allergies or intolerances or are there foods he/she CANNOT have?

If yes, please explain

Are there any special discipline guidelines?

If yes, please explain

Are there any cultural or religious beliefs that you would like to make us aware of?

If yes, please explain

Is there any additional information you would like us to know about your child?

Questions/Comments

Comments/Questions