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Youth Program Health Record IMPORTANT: This form must be filled out completely, signed and returned. Youth's Information: Last Name First Name Middle Preferred name Street Address City State Age:

Please provide a parent signature to the parent section Name: (if a parent/guardian) Phone and email that person will be using to contact Address: Parent's Telephone Number: Email: Age: (Select 1 and 2 in 1:2 or 1:3 order): (Note: In 1:3 order the age will go between 18-24 for both males and females, age greater than 18 will be in this age range for male and female only and older than 24 will not be listed. Select 2 if you do not have any children): What Country Is this resident living in? Please explain how you would like your name to appear in future correspondence. You may email and type on-screen text for your name and address. Name: E-mail Address: I do not have a child to report. Note: if you do not have children reported, you may select No Child under age 24. When completing the form, please ensure that you do not accidentally type a different address each time you enter a cell name or date of birth value. Note: If you are not certain that this person resides in the United States, simply press ENTER or click the link. Note: If you are submitting one of the forms to an organization, please make some effort to find out the person's real and accurate address. Note: If you select No Child under age 24, but are unsure if they reside in the United States, it is recommended you do NOT submit the form. Do you wish to receive information and updates from the California Department of Juvenile Justice about services for youth? If you are a parent or other legal guardian of a juvenile (under age 21), please sign the e-mail to be included on the Youth Report. Click here to view or download California Youth Report Online Click HERE to view PDF copy of youth report form If you wish to update or change information previously provided on this form, please email at least 20 days BEFORE the date printed on the Youth Report. To contact the Department of Human Services Child Support Enforcement Bureau, click HERE To call Human Rights Commission's Help Line, click HERE Note This is not a substitute for your own child custody assessment, and should never be the basis for the court order of custody or placement.

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