Child’s Information

Child for whom this application is made:
Child’s Name
*

Child’s Preferred Name (Nickname)


Child’s Gender
*

Please selectFemaleMale
Child’s Age
*


Child’s Race
*

Please selectAlaskan NativeBlackHawaiian NativePacific IslanderNative AmericanWhiteNot Listed
Please share racial identity if not listed
*


Child’s Eye Color
*

Please selectBlueBrownGreenHazel
Child’s Haircolor
*

Please selectAuburnBlackBlondeBrownRed
Child’s Date of Birth
*


Child’s Place of Birth
*


city, state
Is the child a U.S. citizen?
*

Yes

No
Child’s Religion


Child’s Social Security Number


Child’s Current Address
*

Child’s Email
*


No email address for this child

No email address for this child
Child’s Phone Number
*


No phone number for this child

No phone number for this child

Additional Child Information

Who does this child currently live with?
*


Names of all people currently living in the home and their relationship to the child:
*


What is the child’s understanding of placement at Boys and Girls Country and how do they feel about it?
*






























































































































































































































































































































































If you are human, leave this field blank.


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