Online Enrollment Form

You may enroll for the Successful Futures program online, by completing the form below.

Please review the following statement before submitting your enrollment.

By enrolling in Successful Futures, I authorize thge transfer of pertinent information about me and/or my children to health care providers and agencies participating in the program for referral purposes. I understand and agree that the information transfer can occur by photocopy, electronic file transfer, and/or fax, as the program considers appropriate under the circumstanbces. I also understand that the program includes data collection for the purpose of population studies and quality control and in no way will my children or I be identified personally in data reporting. I understand that this authorization can be revoked in writing at any time after it is signed, and that by notifying a member of the Successful Futures staff I can terminate my participation in Successful Futures. I also understand that this authorization will automatically expire at the end of participation in the Successful Futures program.