INTAKE PACKET

BROTHERS AND KEEPERS CORPORATION

YOUTH INTAKE PACKET
Youth Name *

First Name Last Name
Date of Birth *

- Month - Day Year
CMDP Number *
Participant ID Number *
Medication Needed? *

Yes No
On Probation? *

Yes No
Probation/Parole Officer Information
Behavior Concerns
Medical Concerns
Your answers below represent your consent for Brothers and Keepers Corporation to exercise the following responsibilities or Activities for the listed Youth:

Click YES or NO for Brothers and Keepers Corporation's Consent to the following:

	YES	NO
CONSENT FOR SPORTS: To participate in Sports or Strenuous Activities.
CONSENT FOR MEDICAL TREATMENT: To provide Emergency Dental or Medical Care prescribed by a duly licensed Physician (MD) or Dentist (DDS). This care maybe under whatever conditions are necessary to preserve the Life time or well-being of my dependent.
CONSENT TO TRANSPORT: I consent the youth to be transported by Brothers and Keepers Corporation and its component programs using the company vehicles or the staff’s personal vehicles.
YOUTH GRIEVANCE: I agree that the Youth and/or his parents or legal guardian have the right to file a grievance of dissatisfaction with care, treatment or other services they receive from Brothers and Keepers Corporation. I understand that staff shall not discriminate in any way against any youth or anyone who has participated in an investigative process. I acknowledge receipt of the Brothers and Keepers Corporation Policy and Procedures for Youth’s Grievances. I have read the document and staff have answered my questions about its contents. I understand the document and agree to its terms and conditions.
CREATIVE ARTS: Brothers and Keepers uses creative arts as part of our youth building program. I agree to allow the Youth listed above to be exposed to music development seminars or sessions, video filming sets for teaching directing/producing skills in the film industry, and photography lessons to teach the basic and advanced concepts of digital photography. Through the teachings of all three creative art methods, I understand that the youth may be recorded with video, audio devices, or photography for the purpose of teaching creative arts. Such videos and photography may be used within the company for morale building and use on the company website.

If any answers were clicked NO, please state reason for denial:
Case Manager Name *

First Name Last Name
Case Manager Phone Number *

- Area Code Phone Number
Case Manager E-mail *

Case Manager Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Case Manager REGION *
Supervisor's Name

First Name Last Name
Supervisor's Phone Number

- Area Code Phone Number
Supervisor's E-mail
As the Legal Guardian of the youth listed above, you agree to your answers clicked above.
Case Manager Signature *
Date *

/ Month / Day Year
Should be Empty: