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Residential Education Application

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Source

Today’s Date(Required)

MM slash DD slash YYYY

Name(Required)

First Last

Email(Required)

Birth Date(Required)

MM slash DD slash YYYY

Age(Required)

Sex(Required)

SS#

Race/ Ethnicity(Required)

Other

Church Affiliation

Does the family attend?

Yes

No

Physical Address of Child(Required)

Street Address City State ZIP Code

Height(Required)

Weight(Required)

Hair Color(Required)

Eye Color(Required)

Build S M L Distinguishing Marks(Required)

Tattoos

Reasons for placement of child with Children’s Homes

FAMILY INFORMATION

Mother Information

Mother

Mother Type

Address

Street Address City State ZIP Code

Mother Home Phone

Mother Work Phone

Mother Cell Phone(Required)

Mother DOB

MM slash DD slash YYYY

S.S. #:

Mother Employer

Mother Occupation

Mother Email

Deceased (when, cause)

Military Service

Branch

Type of Discharge

Father Information

Father

Father Type

Address

Street Address City State ZIP Code

Father Home Phone

Father Work Phone

Father Cell Phone

Father DOB

MM slash DD slash YYYY

S.S. #

Father Employer

Father Occupation

Father Email

Deceased (when, cause)

Military Service

Branch

Type of Discharge

Legal Guardian (Person placing child)

Legal Guardian Name

Mailing Address

Street Address City State ZIP Code

Social Security #

Guardian Home Phone

Guardian Work Phone

Guardian Cell Phone

Guardian Email

Guardian Occupation

MEDICAL HISTORY OF CHILD

Physician

Address

Street Address City State ZIP Code

Work Phone

Last Physical

Eye Doctor

Address

Street Address City State ZIP Code

Work Phone

Last Exam

Dentist

Address

Street Address City State ZIP Code

Work Phone

Last Exam

Other

Address

Street Address City State ZIP Code

Work Phone

Last Exam

Insurance

PASSE

Medicaid #

PASSE #

Current Diagnosis

Current Medication

Name

Amount

Reason

Name

Amount

Reason

Name

Amount

Reason

Name

Amount

Reason

Allergies (list what child is allergic to):

EVALUATIONS THIS CHILD HAS HAD

Psychiatric

Where

Date

MM slash DD slash YYYY

Psychological

Where

Date

MM slash DD slash YYYY

Educational

Where

Date

MM slash DD slash YYYY

Neurological

Where

Date

MM slash DD slash YYYY

Comments

CHECK ANY OF THE FOLLOWING THAT APPLY

BATHROOM ISSUES

Bedwetting

Soils self

Runs to bathroom often

Holds back

Loose bowels

TROUBLE MAKING & KEEPING FRIENDS

Feelings easily hurt

Bossy with friends

Afraid not liked

Has no friends

Wants to run things

Shy

Disturbs other children

Picks on others

Runs around with bad crowd

SIBLING PROBLEMS

Feels cheated

Means

Fighting constantly

EDUCATIONAL HISTORY

Please provide accumulative records for consideration of the appropriate school placement. Thanks

Child’s IQ

Current Grade Level

Average Grades

Primary Type of Classroom

Regular

Self Contained

Special Ed (_______# of Students)

Current School

Current School Address

Street Address City State ZIP Code

Principal

Counselor

Current School Phone

Check the following?

Individual Education plan (IEP)

504 plan

PERSONS DENIED CONTACT

Name

Address

Phone

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Date

MM slash DD slash YYYY

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Children's Homes, Inc.

Want to Know More About Our Mission?

5515 Walcott Road
Paragould, AR 72450

asweeney@childrenshomes.org

(479) 886-4289