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First Participant's (18+) Name

First Name*

Last Name*

Phone*
First Participant's (18+) Date of Birth*
First Participant's (18+) Signature*
Second Participant's (18+) Name

First Name*

Last Name*
Second Participant's (18+) Date of Birth*
Third Participant's (18+) Name

First Name*

Last Name*
Third Participant's (18+) Date of Birth*
Fourth Participant's (18+) Name

First Name*

Last Name*
Fourth Participant's (18+) Date of Birth*
Fifth Participant's (18+) Name

First Name*

Last Name*
Fifth Participant's (18+) Date of Birth*
Sixth Participant's (18+) Name

First Name*

Last Name*
Sixth Participant's (18+) Date of Birth*
Seventh Participant's (18+) Name

First Name*

Last Name*
Seventh Participant's (18+) Date of Birth*
Eighth Participant's (18+) Name

First Name*

Last Name*
Eighth Participant's (18+) Date of Birth*
Ninth Participant's (18+) Name

First Name*

Last Name*
Ninth Participant's (18+) Date of Birth*
Tenth Participant's (18+) Name

First Name*

Last Name*
Tenth Participant's (18+) Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Tell Us More!

Austin17House is aware of many of the social determinants that affect our youth and families today, and we work closely with organizations and partners to ensure that all participants and members who join us have options for support where needed. As a non-profit organization we also have opportunities to receive grants and donations for families who are in any public assistance programs. 


Does your family participate in any public assistance programs?
Free and reduced price school (breakfast, lunch, supper)
TANF
Food Pantry/Soup Kitchen
Public Housing/Section 8
Food Stamps/SNAP
WIC/CSFP
Heat/Electric Assistance
SSDI
Head Start
Town Welfare
Medicaid
SSI
Wrap Around Services
IEP
504
What other resources would you, or your family be interested in?
Youth Recovery Services
Adult Recovery Services
Mental Health Resources
Transportation Services
Food/Grocery Services
Medical Services
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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