FORMS

Outreach Intake Form

(Children/minors under the age of 18)

(Please have accompanying parent or guardian fill out form)

First Name of Child

Last Name of Child

Date of Birth

Organization Name

Address 1

Address 2

City

State

ZIP

Parent/Guardian Email Address

Parent/Guardian Home Phone

Parent/Guardian Cell Phone

How old is your child?

Would you consider your child to be an introvert, extrovert, or mix of both?

Introvert Extrovert Mix of Both

What interests your child? (sports, hobbies, etc)

In the past few years, has your child experienced any major life-changing transitions or issues?

Does your child like dogs and if so, do you believe that spending time with dogs can be therapeutic in any way for conditions that your child may be experiencing?

Yes No

Has your child been in close physical contact with anyone who tested positive for COVID-19 or has exhibited COVID-19 symptoms in the past 2 weeks?

Yes No

Are you currently waiting on the results of a COVID-19 test for your child?

Yes No

Have you traveled with your child in the past 10 days?

Yes No

Agreement

I hereby state that my answers to the questions provided above are true and correct to the fullest extent of my knowledge, information and belief.

Signature of Parent/Guardian of Minor Van of Promise Patient (sign with finger, mouse, or trackpad)

Printed Name of Parent/Guardian of Minor Van of Promise Patient

Agreement

As the parent of the child referenced below, I hereby consent to my child’s participation in activities orchestrated by “The Van of Promise” with the “Life Path Institute” and/or the employees of either entity.

Name of child/minor 18 years or younger:

Signature of Parent/Guardian of Minor Van of Promise Patient (sign with finger, mouse, or trackpad)

Printed Name of Parent/Guardian of Minor Van of Promise Patient

FORMS

Outreach Intake Form

CONTACT

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