DREAM Youth Information Update Form

Please complete the following form to update the contact information, emergency contact, and allergy/health information we have for your child. This information will help us better respond in the case of an emergency. Please be in touch with your DREAM Contact Person or call (802) 388-8979 if you have any questions or difficulty submitting this form. Thank you!

Youth Information

First Name of Youth *

Last Name of Youth *

Nickname/Preferred Name

Date of Birth * +

Gender

Race/Ethnicity

Household Language(s). Choose all that you speak/read. *

Community Youth Lives In *

School Youth Attends

Grade Entering September 2021. Note: if your child is entering Kindergarten, please enter "0".

Youth Home Phone Number *

Youth Personal Cell Phone Number (if none, please leave blank).

Youth Personal Email Address (if none, please leave blank.)

Has the youth moved or have an updated address? *

Yes

No

Primary Street Address (with apartment number) *

City

State

Zip Code

Parent/Guardian Information

Does the youth have a new primary guardian or caretaker? *

Yes

No

Do the parent(s), guardian(s) and/or caretaker(s) of the youth have a new phone number, email address, or preferred way to be contacted by DREAM? *

Yes

No

Parent/Guardian #1:

First Name of Parent/Guardian (1) *

Last Name of Parent/Guardian (1) *

Relationship to Child (1) *

Primary Phone Number (1) *

Secondary Phone Number (1)

Parent/Guardian Email address (1)

Preferred method of contact for updates on daily schedules and programs. (1) *

Text

Phone Call

Email

Parent/Guardian #2:

First Name of Parent/Guardian (2)

Last Name of Parent/Guardian (2)

Relationship to Child (2)

Primary Phone Number (2)

Secondary Phone Number (2)

Parent/Guardian Email Address (2)

Preferred method of contact for updates on daily schedules and programs. (2)

Text

Phone Call

Email

Emergency Contact Information (different from parent/guardian)

Does the youth have a new emergency contact person? *

Yes

No

Do any of the youths' emergency contacts have a new phone number? *

Yes

No

Emergency Contact #1:

First and Last Name (1) *

Relationship to Youth (1) *

Phone Number (1) *

Can we text Emergency Contact #1? *

Yes

No

Emergency Contact #2:

First and Last Name (2)

Relationship to Youth (2)

Phone Number (2)

Can we text Emergency Contact #2?

Yes

No

Emergency Contact #3:

First and Last Name (3)

Relationship to Youth (3)

Phone Number (3)

Can we text Emergency Contact #3?

Yes

No

If applicable, list the name of any emergency contacts on file who should be removed.

These people can pick up/ drop off/ accept the youth:

	Yes	No	N/A
Emergency Contact #1	Yes	No	N/A
Emergency Contact #2	Yes	No	N/A
Emergency Contact #3	Yes	No	N/A

People who can pick up/ drop off/ accept youth:

	Full Name (for additional individuals)	Relationship to Youth	Phone Number
#1	Full Name (for additional individuals)	Relationship to Youth	Phone Number
#2	Full Name (for additional individuals)	Relationship to Youth	Phone Number
#3	Full Name (for additional individuals)	Relationship to Youth	Phone Number

If applicable, provide the name of anyone who should be removed from the list to pick up the youth.

The DREAM Program operates with a core value of inclusion, and strives to be supportive of all participants regardless of their race, color, sex, sexual orientation, gender identity, religion, disability, age, veteran status, ancestry, or national or ethnic origin.

Arabic	Burmese
Chinese / Mandarin	English
French	Haitian Creole
Hindi	Khmer
Kirundi / Rundi	Korean
Mai-Mai	Nepali
Portuguese	Spanish
Somali	Swahili
Vietnamese	Other Other