Enroll a young person in a Youth R Us program.

Programs are offered at no cost to qualifying families. Ages 5 to 18 across Detroit and Metro Detroit.

1 · Apply

Tell us about your young person and the support they need.

2 · Review

A team member reaches out within 5 business days to learn more.

3 · Match

We match the youth with the right program track and counselor.

4 · Enroll

Welcome to Youth R Us, your journey of healing and growth begins.

Application

Youth Services Application

Please complete every section as fully as you can. All information is kept confidential and used only to match your young person with the right program and counselor. Need help? Email info@youthrus.net or call (313) 555-0100.

1 · Youth Information

First name *Last name *Date of birth *Age *GenderPronouns

2 · Parent / Guardian

First name *Last name *Relationship to youth *Email *Primary phone *Alternate phone

3 · Household

Street address *

City *State *ZIP *

People in householdApproximate annual household income

4 · School

School nameGradeIEP or 504 plan?

5 · Emergency Contact

Full name *Phone *Relationship *

6 · Medical & Wellness

Allergies (food, environmental, medication)Current medicationsMental health, behavioral, or medical conditions we should be aware of

8 · Tell Us Their Story

Briefly describe what is happening for your young person and what kind of support they need. *What outcomes or goals do you hope this program will help them reach?

9 · Consent & Signature

I authorize Youth R Us Foundation to contact me about this application by phone, email, or text. *I grant permission for my young person to be photographed or recorded during program activities for non-commercial promotional use. (Optional)I certify that the information provided is accurate and I release Youth R Us Foundation and its staff from liability for typical program activities. *

Parent / guardian signature (type full name) *Date *

By submitting you agree to our confidentiality and privacy practices.