Enroll with
Guided Grace FYS.

*Program Site Name:

Student Information

Gender

Parent / Legal Guardian Contact Information

Emergency Contacts(Authorized for Pick Up If Needed)

Health and Medical Information:

If medication is to be distributed during the program, I understand that a medication authorization form must be on file with the program leadership _______ (initials) and it is my responsibility to make sure the leadership has the authorized medication to be administered in a timely manner _____(initials)

Parent / Legal Guardian Consent and Authorizations

Please read the statement below and check the box next to each statement

Guided Grace FYS Group Services

As part of the Out-of-School Time (OST) program, Guided Grace will be delivering therapeutic group sessions and enrichment activities. Guided Grace is the service provider working in partnership with Guided Grace Family & Youth Services (GGFYS) to ensure high-quality, supportive programming for all enrolled youth. Insurance information is optional. You can enroll even if your child does not have insurance or you do not have the information available. If provided, insurance information helps Guided Grace coordinate care and, if applicable, manage billing for group sessions.

If available, you may attach photos of the front and back of your child’s insurance card below. Insurance details and card copies are optional and do not prevent enrollment. Please note that all information will be kept confidential and used solely for the purposes of coordinating care and services. By Signing my student up, I authorize this program to collect and use data about my child for the purposes of program development, safety, and improving educational outcomes. I understand that this data will be kept confidential, stored securely, and used by authorized personnel within the organization, and shared with Michigan Department of LifeLong Education, Advancement and Potential (MiLEAP) 32n OST Grants Program and state evaluation partners.