Network for Safe Families 

 
 

A program of SCAN, Inc.

  
Fax Number: 260-421-5003

Extension Form

 Telephone: 800-752-7116

Serving:    

Adams, Allen, DeKalb, Huntington, LaGrange, Noble, Steuben, Wells

 & Whitley 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........: