OTFA
Online Referral Form
Step 1 of 15
Youth Demographic Information
First Name:
Middle Name:
Last Name:
Nickname:
Date of Birth:
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1996
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1998
1999
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2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
Height:
Feet
Inches
Weight:
Lbs.
Hair Color:
Blonde
Brown
Black
Red
Other/Unknown
Eye Color:
Blue
Brown
Black
Green
Grey
Other/Unknown
Race:
Asian/Pac Inslander
Black
Hispanic
Indian/Alaskan Native
Other
White
Religion:
Sex:
Male
Female
Social Security
Number:
-
-
FACSIS #:
(If available)
Who holds Custody/Legal Guardianship:
Physical Marks/Features: