PARENT INTAKE FORM

EMPLOYMENT INFORMATION

SPOUSE INFORMATION IF JOINT MEMBERSHIP

SPOUSE EMPLOYMENT INFORMATION

REFERRAL BY (GIVE NAME, ADDRESS, PHONE & EMAIL)

ADDITIONAL INFORMATION

SIGNATURES

Authorization to Exchange/Drop off or Pick Up Child

Custodial Parent Only

to pick up my children in lieu of myself. I understand that parties I authorize will also be required to follow Arizonans for Children guidelines and rules regarding exchanges and visitations. I understand that they may be required by Arizonans for Children staff to show a driver's license as proof of identification. Failure to provide identification may result in children not being released to that party.

SIGNATURES