Make a Referral Refer someone you know to the On The Path Program. "*" indicates required fields Date* MM slash DD slash YYYY Youth's Name* First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Race*American Indian or Alaska NativeAsianBi-racialBlack or African AmericanDeclined to specifyEuropeanLatin American/HispanicNative Hawaiian or Other Pacific IslanderOtherWhiteSocial Security NumberYouth's Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*Appling CountyAtkinson CountyBacon CountyBaker CountyBaldwin CountyBanks CountyBarrow CountyBartow CountyBen Hill CountyBerrien CountyBibb CountyBleckley CountyBrantley CountyBrooks CountyBryan CountyBulloch CountyBurke CountyButts CountyCalhoun CountyCamden CountyCandler CountyCarroll CountyCatoosa CountyCharlton CountyChatham CountyChattahoochee CountyChattooga CountyCherokee CountyClarke CountyClay CountyClayton CountyClinch CountyCobb CountyCoffee CountyColquitt CountyColumbia CountyCook CountyCoweta CountyCrawford CountyCrisp CountyDade CountyDawson CountyDecatur CountyDeKalb CountyDodge CountyDooly CountyDougherty CountyDouglas CountyEarly CountyEchols CountyEffingham CountyElbert CountyEmanuel CountyEvans CountyFannin CountyFayette CountyFloyd CountyForsyth CountyFranklin CountyFulton CountyGilmer CountyGlascock CountyGlynn CountyGordon CountyGrady CountyGreene CountyGwinnett CountyHabersham CountyHall CountyHancock CountyHaralson CountyHarris CountyHart CountyHeard CountyHenry CountyHouston CountyIrwin CountyJackson CountyJasper CountyJeff Davis CountyJefferson CountyJenkins CountyJohnson CountyJones CountyLamar CountyLanier CountyLaurens CountyLee CountyLiberty CountyLincoln CountyLong CountyLowndes CountyLumpkin CountyMacon CountyMadison CountyMarion CountyMcDuffie CountyMcIntosh CountyMeriwether CountyMiller CountyMitchell CountyMonroe CountyMontgomery CountyMorgan CountyMurray CountyMuscogee CountyNewton CountyOconee CountyOglethorpe CountyPaulding CountyPeach CountyPickens CountyPierce CountyPike CountyPolk CountyPulaski CountyPutnam CountyQuitman CountyRabun CountyRandolph CountyRichmond CountyRockdale CountySchley CountyScreven CountySeminole CountySpalding CountyStephens CountyStewart CountySumter CountyTalbot CountyTaliaferro CountyTattnall CountyTaylor CountyTelfair CountyTerrell CountyThomas CountyTift CountyToombs CountyTowns CountyTreutlen CountyTroup CountyTurner CountyTwiggs CountyUnion CountyUpson CountyWalker CountyWalton CountyWare CountyWarren CountyWashington CountyWayne CountyWebster CountyWheeler CountyWhite CountyWhitfield CountyWilcox CountyWilkes CountyWilkinson CountyWorth CountyYouth's Home Phone*Parent Guardian Name* First Last Parent / Guardian Phone Number*Parent / Guardian Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance TypeInsurance NumberSchoolGradeName of Person Making Referral* First Last Referral Contact Email* Referral Phone Number*Relationship to Youth*Reason for Referral*DJJ Involvement* Yes No DFCS Custody or Involvement* Yes No Reason for InvolvementCurrent Medications:Signature*Consent* I agree to the privacy policy.The Regeneration Project, LLC dba On The Path Children and Family Services (“us”, “we”, or “our”) operates the https://www.onthepathga.com website (the “Service”). This page informs you of our policies regarding the collection, use, and disclosure of personal data when you use our Service and the choices you have associated with that data. We use your data to provide and improve the Service. By using the Service, you agree to the collection and use of information in accordance with this policy. Unless otherwise defined in this Privacy Policy, terms used in this Privacy Policy have the same meanings as in our Terms and Conditions, accessible from https://www.onthepathga.com Information Collection And Use We collect several different types of information for various purposes to provide and improve our Service to you. Types of Data Collected Personal Data While using our Service, we may ask you to provide us with certain personally identifiable information that can be used to contact or identify you (“Personal Data”). Personally identifiable information may include, but is not limited to: Email address First name and last name Phone number Address, State, Province, ZIP/Postal code, City Cookies and Usage Data Usage Data We may also collect information how the Service is accessed and used (“Usage Data”). This Usage Data may include information such as your computer’s Internet Protocol address (e.g. IP address), browser type, browser version, the pages of our Service that you visit, the time and date of your visit, the time spent on those pages, unique device identifiers and other diagnostic data. Tracking & Cookies Data We use cookies and similar tracking technologies to track the activity on our Service and hold certain information. Cookies are files with small amount of data which may include an anonymous unique identifier. Cookies are sent to your browser from a website and stored on your device. Tracking technologies also used are beacons, tags, and scripts to collect and track information and to improve and analyze our Service. You can instruct your browser to refuse all cookies or to indicate when a cookie is being sent. However, if you do not accept cookies, you may not be able to use some portions of our Service. Examples of Cookies we use: Session Cookies. We use Session Cookies to operate our Service. Preference Cookies. We use Preference Cookies to remember your preferences and various settings. Security Cookies. We use Security Cookies for security purposes. Use of Data The Regeneration Project, LLC dba On The Path Children and Family Services uses the collected data for various purposes: To provide and maintain the Service To notify you about changes to our Service To allow you to participate in interactive features of our Service when you choose to do so To provide customer care and support To provide analysis or valuable information so that we can improve the Service To monitor the usage of the Service To detect, prevent and address technical issues Transfer Of Data Your information, including Personal Data, may be transferred to — and maintained on — computers located outside of your state, province, country or other governmental jurisdiction where the data protection laws may differ than those from your jurisdiction. If you are located outside United States and choose to provide information to us, please note that we transfer the data, including Personal Data, to United States and process it there. Your consent to this Privacy Policy followed by your submission of such information represents your agreement to that transfer. The Regeneration Project, LLC dba On The Path Children and Family Services will take all steps reasonably necessary to ensure that your data is treated securely and in accordance with this Privacy Policy and no transfer of your Personal Data will take place to an organization or a country unless there are adequate controls in place including the security of your data and other personal information. Disclosure Of Data Legal Requirements The Regeneration Project, LLC dba On The Path Children and Family Services may disclose your Personal Data in the good faith belief that such action is necessary to: To comply with a legal obligation To protect and defend the rights or property of The Regeneration Project, LLC dba On The Path Children and Family Services To prevent or investigate possible wrongdoing in connection with the Service To protect the personal safety of users of the Service or the public To protect against legal liability Security Of Data The security of your data is important to us, but remember that no method of transmission over the Internet, or method of electronic storage is 100% secure. While we strive to use commercially acceptable means to protect your Personal Data, we cannot guarantee its absolute security. Service Providers We may employ third party companies and individuals to facilitate our Service (“Service Providers”), to provide the Service on our behalf, to perform Service-related services or to assist us in analyzing how our Service is used. These third parties have access to your Personal Data only to perform these tasks on our behalf and are obligated not to disclose or use it for any other purpose. Analytics We may use third-party Service Providers to monitor and analyze the use of our Service. Google AnalyticsGoogle Analytics is a web analytics service offered by Google that tracks and reports website traffic. Google uses the data collected to track and monitor the use of our Service. This data is shared with other Google services. Google may use the collected data to contextualize and personalize the ads of its own advertising network.You can opt-out of having made your activity on the Service available to Google Analytics by installing the Google Analytics opt-out browser add-on. The add-on prevents the Google Analytics JavaScript (ga.js, analytics.js, and dc.js) from sharing information with Google Analytics about visits activity.For more information on the privacy practices of Google, please visit the Google Privacy & Terms web page: https://policies.google.com/privacy?hl=en Links To Other Sites Our Service may contain links to other sites that are not operated by us. If you click on a third party link, you will be directed to that third party’s site. We strongly advise you to review the Privacy Policy of every site you visit. We have no control over and assume no responsibility for the content, privacy policies or practices of any third party sites or services. Children’s Privacy Our Service does not address anyone under the age of 18 (“Children”). We do not knowingly collect personally identifiable information from anyone under the age of 18. If you are a parent or guardian and you are aware that your Children has provided us with Personal Data, please contact us. If we become aware that we have collected Personal Data from children without verification of parental consent, we take steps to remove that information from our servers. Changes To This Privacy Policy We may update our Privacy Policy from time to time. We will notify you of any changes by posting the new Privacy Policy on this page. We will let you know via email and/or a prominent notice on our Service, prior to the change becoming effective and update the “effective date” at the top of this Privacy Policy.108 Byrd Way, Suite 400 Warner Robins, GA 31088 (478) 953-0330 Phone (478) 953-0368 FaxThis field is hidden when viewing the formUntitled*EmailThis field is for validation purposes and should be left unchanged. Get In Touch "*" indicates required fields Name* First Last PhoneEmail* NotesThis field is hidden when viewing the formUntitled*CommentsThis field is for validation purposes and should be left unchanged.
