Community Partners for Safe Families 

 
 

A program of SCAN, Inc.

  
Fax Number: 260-421-5003

Extension Form

 Telephone: 800-752-7116
 

Serving Elkhart, Marshall, St. Joseph and Kosciusko Counties

  
     
  Family Number.................... Consent Date.....................
 

 Why additional time is being requested for the family..

 
Agency Name:   Agency Phone#:

Authorized Requester's Name........:

 
 Authorized Requester's Email........: