Beaumont Middle School Youth Services Center Intake Form
Please complete this form and consider your submission of this form your release of information to the YSC to work on your behalf to provide services requested.  The YSC Coordinator will contact you to collect any additional secure information.
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Student Name (Sibling names can be added below) *
Student Birthdate *
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Street Address *
City, State, Zip Code *
Sibling Name
Sibling Birthdate
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Sibling Name
Sibling Birthdate
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Sibling Name
Sibling Birthdate
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Parent/Guardian Name *
Parent Birthdate *
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Parent Cell Phone *
Parent Work Phone
Total Number of Adults Living in Household *
Total Number of Children Living in Household *
Please list names of all other adults in the household - Please include a birthdate.  Please type NONE if no other adults reside in the home. *
Average Monthly Income for Household *
Briefly explain your current situation and why you are seeking help. *
Please list the full name of the person completing this form. *
Please initial below authorizing the BMS YSC to contact any agencies on your behalf.            I give my permission for the following agencies, participating with the Fayette County Family Resource and Youth Services Centers, to exchange information and service in meeting the needs of my family.  Adult Education  * Christians in Community Service * Cooperative Extension Center * Insurance Assistance *   Cabinet for Families and Children * Church Based Assistance * Family Care Center * Rental Assistance * Medical/Health Referral * Child Care Council * Community Action Council  * God’s Pantry * UK College of Dentistry * Christ Community Cupboard    * Comprehensive Care * Health Department * Utilities (KU, Columbia Gas,  etc.) Or other agency as requested by family/center.                                         *
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