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2. 
3. City of Westland Youth Assistance Program Youth Client Referral Form/Face Sheet

   All information provided in this form is subject to Freedom of Information Act requests subject to State law.

5. Referral Source*
   -- Select One --Juvenile CourtSchoolPoliceVoluntaryOther
7. Referred By*
8. Referral Phone Number*
9. Referral Email
11. Youth Name*
12. Youth Birthdate
13. Sex
15. Youth Home Address
16. City
17. Zip Code
19. Youth School Name
20. Youth Grade
21. School District
23. Parent/Guardian Name*
24. Parent/Guardian Birthdate
26. Parent/Guardian Home Address
27. City
28. Zip Code
30. Parent/Guardian - Home Phone*
31. Parent/Guardian - Cell Phone*
33. Parent/Guardian Email
35. Brief Description of Referral*
37. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
39. Electronic Signature*
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field