California Youth Services - Helping Teens Make Positive Decisions  
 

How to Enroll

You can click here to download the Enrollment Form which can be mailed or faxed. Requires Adobe Reader (free).

* Required Fields
 
Date Referred / /
Program
Location
Juvenile Last Name *
Juvenile First Name *
Mom Last Name
Mom First Name
Dad Last Name
Dad First Name
Biological Parents?
Parent's Marital Status
Address
City
State
Zip
Juvenile Age
Juvenile Date of Birth / /
Gender


Ethnicity
School Attended/Suspended From
In Trouble/Cited For...
PRYDE Diversion Specialist
Ever attended a diversion program?


If yes, list:
Home Phone #   *
Cell Phone #  
Work Phone #
Referring Agency/Person