I have been provided information on the referenced Family Support Services Program and wish to receive services. I understand that data on my child/youth/family will be collected, maintained, and entered into a secure database. The information will be used to track services for evaluation purposes and to ensure quality services are being provided. I hereby authorize my child/youth/family to participate in the program.
Check 'Yes' for all priority characteristics that are known at the time of enrollment. Check 'No' for those that do not apply and/or are not known at the time of enrollment. Per grant requirements, 2 or more must be selected.
Asterisks (*) denote priority characteristics that are identified as priority service populations in authorizing Maternal, Infant, and Early Childhood Home Visiting (MIECHV) legislation and in Texas Home Visiting (THV). THV grantees must give priority in providing services to these populations as relevant.
