South Central Youth and Family Services

Family Rewards Program

Application

Families can enroll when they are pregnant and/or

Until baby is 6 months of age

Process:

v  Participants receive referral form from agency or receive an enrollment form

v  Participants go to the Family Rewards Center and fill out an enrollment survey.

v  Participants receive a Point card and list of where they can get points from Family Rewards Program Coordinator

Duration of Client Eligibility:

Participant can remain in the Family Rewards program until baby reaches 18 months of age.  If another pregnancy occurs before expiration of current enrollment, the old card will be terminated and a new registration and membership card put in place starting registration date as the current date or date of new pregnancy.  The points will then be transferred to the new card.

v  The American College of Obstetricians and Gynecologist (ACOG) recommends 2 years and 7 months between pregnancy for the health of the mother and the health of the child

Fraud Policy:

All point cards will be reviewed at each purchase.  Any questions will be verified by the agency awarding the points.  Point cards need to be shown to the provider at the time of the visit to received points for that visit.  Any individual who alters their point card will no longer be eligible for the Family Rewards Program now or in the future.  No exceptions will be made.

__________________________            ____________________                   

Participant signature                                    Date

______________________________            ____________________

Family Rewards staff signature                   Date

After you have filled out this form, please mail it to:

FAMILY REWARDS

 P.O. Box 355

Indianola, IA 50125

Call 515-961-3153 (Warren County) or 641-743-2449 (Adair County) for more information.