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Holmes Youth Services Center Service Request Form
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* Indicates required question
Parent/Guardian Name:
*
Your answer
Student Name:
*
Your answer
Student Grade:
*
Choose
6
7
8
9
10
11
12
Home Address:
*
Your answer
Telephone Number:
*
Your answer
This number is my:
*
Choose
Home
Cell
Email Address:
*
Your answer
Do you have other children in Covington Independent Public Schools?
*
Choose
Yes
No
If Yes, please give us his/her name, school name and grade:
Your answer
Please check which service you are requesting for your child/family:
*
Food
Eyeglasses
Medical/Dental Care
Mental Health Referral
School Supplies
Employment Assistance Referral
Clothing
Substance Abuse Prevention Assistance Referral
Other:
Required
If you chose school supplies, please specify:
Your answer
If you chose clothing, please specify shirt size:
Choose
Youth
Juniors
Husky
Adult
If you chose clothing, please specify pant size:
Choose
Youth
Juniors
Husky
Adult
By checking this box, I certify that the above information is correct.
*
I agree
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