Child’s Information

Child for whom this application is made:

Child’s Name

Child's Name

First

Middle

Last

Child’s Preferred Name (Nickname)

Child’s Gender Child's Gender

Child’s Age

Child’s Race

Please share racial identity if not listed

Child’s Eye Color

Child’s Haircolor

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 Current Address

City

State/Province

Zip/Postal

Child’s Email

No email address for this child

Child’s Phone Number

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?

Who is submitting this application?

Name

First

Middle

Last

What is your relationship to this child?

Are you submitting this application on behalf of someone else?

Yes

No

If yes, who?

Email

Phone

Please share your reason(s) for seeking placement for this child:

Are you the legal guardian of this child?

Yes

No

Legal Guardian Information

Same as submitter

Same as above

Legal Guardian “A” Information (LGA)

(LGA) Name

First

Middle

Last

(LGA) Phone Number

(LGA) Email

Legal Guardian “A” Information (LGA)

(LGA) Previous Name (if applicable)

First

Middle

Last

(LGA) Date of Birth

(LGA) Age

(LGA) Gender

(LGA) Religion

(LGA) Social Security Number

(LGA) Place of Birth

city, state

(LGA) Address

City

State/Province

Zip/Postal

Country

(LGA) Marriage Status

(LGA) Marriage History

full names of previous spouses – dates of separation

(LGA) Children Born To This Parent

full names, dates of birth, current city where they live

(LGA) Highest Level of Education Completed

(LGA) Employment Information

(LGA) Employer

(LGA) Job Title / Description

(LGA) Estimated Income Payment Frequency

weekly, hour, monthly, annual

(LGA) Work Phone Number

Legal Guardian “B” Information (LGB)

(LGB) Name

First

Middle

Last

(LGB) Previous Name (if applicable)

First

Middle

Last

(LGB) Phone Number

(LGB) Email

(LGB) Date of Birth

(LGB) Age

(LGB) Gender

(LGB) Religion

(LGB) Social Security Number

(LGB) Place of Birth

city, state

(LGB) Address

City

State/Province

Zip/Postal

Country

(LGB) Marriage Status

(LGB) Marriage History

full names of previous spouses – dates of separation

(LGB) Children Born To This Parent

full names, dates of birth, current city where they live

(LGB) Highest Level of Education Completed

(LGB) Employment Information

(LGB) Employer

(LGB) Job Title / Description

(LGB) Estimated Income Payment Frequency

weekly, hour, monthly, annual

(LGB) Work Phone Number

Please complete the following ONLY if the parent’s information is different than the current legal guardians

Parent “A” Information (PA)

Same as Legal Guardian “A” (LGA)

Parent “A” Information (PA)

(PA) Name

First

Middle

Last

(PA) Previous Name (if applicable)

First

Middle

Last

(PA) Phone Number

(PA) Email

(PA) Date of Birth

(PA) Age

(PA) Gender

(PA) Religion

(PA) Social Security Number

(PA) Place of Birth

city, state

(PA) Address

City

State/Province

Zip/Postal

Country

(PA) Marriage Status

(PA) Marriage History

full names of previous spouses – dates of separation

(PA) Children Born To This Parent

full names, dates of birth, current city where they live

(PA) Highest Level of Education Completed

Parent “A” (PA) Employment Information

(PA) Employer

(PA) Job Title / Description

(PA) Estimated Income Payment Frequency

weekly, hour, monthly, annual

(PA) Work Phone Number

Parent “B” Information (PB)

Same as Legal Guardian “B” (LGB)

Parent “B” Information (PB)

(PB) Name

First

Middle

Last

(PB) Previous Name (if applicable)

First

Middle

Last

(PB) Phone Number

(PB) Email

(PB) Date of Birth

(PB) Age

(PB) Gender

(PB) Religion

(PB) Social Security Number

(PB) Place of Birth

city, state

(PB) Address

City

State/Province

Zip/Postal

Country

(PB) Marriage Status

(PB) Marriage History

full names of previous spouses – dates of separation

(PB) Children Born To This Parent

full names, dates of birth, current city where they live

(PB) Highest Level of Education Completed

Parent “B” (PB) Employment Information

(PB) Employer

(PB) Job Title / Description

(PB) Estimated Income Payment Frequency

weekly, hour, monthly, annual

(PB) Work Phone Number

Income / Financial Benefits Child Receives

Select all that apply

Social Security

Child Support

(TANF)

Other

Social Security Claim Number

Child Support Amount

$

(TANF) Amount

$

Other Income Amount

$

Other Income Type

Child’s Behavior

Is this child physically aggressive?

Yes

No

Please explain physically aggressive behavior

Has this child ever self-harmed or threatened self-harm?

Yes

No

Please explain self-harm behavior in detail

Does this child have a history of alcohol abuse?

Yes

No

Please explain alcohol abuse behavior

Does this child have a history of smoking or vaping?

Yes

No

Please explain smoking or vaping behavior (cigarettes, vape pens, etc)

Does this child have a history of drug abuse?

Yes

No

Please explain drug abuse behavior including substances used (marijuana, opioids, etc)

Child’s Mental Health

Has this child ever received a mental health diagnosis?

Yes

No

Please give details of any (all) mental health diagnosis

Has this child ever been placed in a residential treatment facility or psychiatric hospital?

Yes

No

Please share details of residential or psychiatric treatment received

Does this child currently have any mental health needs that require treatment?

Yes

No

Please explain current mental health needs

Please list all medical professional who have contact with the family (ex: psychiatrist, counselor, doctor)

title, name, contact information

Child’s Background

Has this child experienced physical abuse?

Yes

No

Unknown

Details surrounding physical abuse:

relationship to abuser and child’s age when abuse occurred

Has this child experienced sexual abuse?

Yes

No

Unknown

Details surrounding sexual abuse:

relationship to abuser and child’s age when abuse occurred

Has this child experienced emotional abuse?

Yes

No

Unknown

Details surrounding emotional abuse:

relationship to abuser and child’s age when abuse occurred

Has this child experienced neglect?

Yes

No

Unknown

Details surrounding neglect:

relationship to abuser and child’s age when neglect occurred

Has this child experienced abandonment?

Yes

No

Details surrounding abandonment:

relationship to abuser and child’s age when abandonment occurred

Please list all government agencies who have had contact with the family:

Caseworkers, CPS, School Administrators, Texas Department of Family and Protective Services (DFPS)

Child’s Birth Information

please answer to the best of your knowledge

Length

Weight

Premature Birth

Yes

No

Unknown

C-Section

Yes

No

Unknown

Normal Delivery

Yes

No

Unknown

Average Health At Birth

Yes

No

Unknown

Injury At Birth

Yes

No

Unknown

Hospitalized After Birth

Yes

No

Unknown

Please list any significant factors related to the pregnancy or birth of this child:

Child’s Development

Speech Delay or Impairment

Yes

No

Please explain speech delay or impairment

Motor Skills Delay or Impairment

Yes

No

ex: walking

Please explain motor skills delay or impairment

Physical Disability or Impairment

Yes

No

Please explain any physical disability or impairment

Social Skills Disability or Impairment

Yes

No

Please explain social skills disability or impairment

Emotional Impairment

Yes

No

emotional and behavioral disorder

Please explain emotional or behavioral issues

Intellectual Disability or Impairment

Yes

No

Please explain intellectual disability or impairment

Child’s Medical History

Any previous hospitalizations?

Yes

No

Please explain hospitalizations

Any previous surgeries?

Yes

No

Please explain surgeries

Any significant past injuries?

Yes

No

Please explain past injuries

Has this child had the chicken pox?

Yes

No

At what age did this child have the chicken pox?

Has this child reached puberty?

Yes

No

Unknown

have they had their first menstrual cycle (females)

Child’s Immunizations

Are their immunizations current?

Yes

No

Unknown

Any known reactions to previous immunizations?

Yes

No

Please explain reactions to any previous immunizations

name of vaccine, type of reaction, age that it occurred

You will be asked to provide their immunization records during placement process

Child’s General Health

Any known allergies to food or medications?

Yes

No

Please explain food or medication allergy and type of reaction

Please provide details for all general health problems selected above

Any serious illnesses?

Yes

No

Please explain serious illnesses

Is child often sick with minor ailments?

Yes

No

Please explain minor ailments

Does child frequently complain or fake illness or ailments?

Yes

No

Please explain frequent complaints or faked ailments

Does this child have an unreasonable fear of doctors or needles?

Yes

No

Please provide details of their fear of doctors or needles

Any problems related to sleeping?

Yes

No

Please explain any problems or factors related to sleeping

How is the child’s personal hygiene and grooming?

Poor

Good

Great

Does this child have any medical problems that need attention at this time?

Yes

No

Please explain current medical or physical problems that need attention

How is this child’s overall health?

Poor

Good

Excellent

In your own words, how would you describe this child’s overall health?

Child’s Medication History

Please list all medications this child is currently taking

Please list all previous medications this child has taken for physical, emotional or behavioral disorders

Child’s Health Insurance

Does this child have health insurance?

Yes

No

Health Insurance Information

Health Insurance Provider

Insurance Phone Number

Group Information

Policy Number

Subscriber Name

First

Last

Relationship to Child

Biological Family Medical History

please answer to the best of your ability

Asthma History

Mother’s Side

Father’s Side

Both

Diabetes History

Mother’s Side

Father’s Side

Both

High Blood Pressure History

Mother’s Side

Father’s Side

Both

Obesity History

Mother’s Side

Father’s Side

Both

Multiple Sclerosis History

Mother’s Side

Father’s Side

Both

Seizures History

Mother’s Side

Father’s Side

Both

Migraines History

Mother’s Side

Father’s Side

Both

Thyroid Disease History

Mother’s Side

Father’s Side

Both

Cystic Fibrosis History

Mother’s Side

Father’s Side

Both

Cancer History

Mother’s Side

Father’s Side

Both

Tuberculosis History

Mother’s Side

Father’s Side

Both

Stroke History

Mother’s Side

Father’s Side

Both

Blood Disorder History

Mother’s Side

Father’s Side

Both

Birth Defect History

Mother’s Side

Father’s Side

Both

Heart Diease History

Mother’s Side

Father’s Side

Both

High Blood Pressure History

Mother’s Side

Father’s Side

Both

Intellectual Disability History

Mother’s Side

Father’s Side

Both

Other History

Mother’s Side

Father’s Side

Both

Please explain “other”

Child’s Education

Name of school they are currently enrolled at:

(if you are applying during the summer, what was the last school they attended)

Current Grade In School Current Grade In School

(if you are applying during the summer, what grade to they plan to attend in the fall)

Have they ever repeated a grade in school?

Yes

No

Please share what grades they have repeated

Has this child ever been suspended or expelled from school?

Yes

No

Please explain suspension or expulsion

Are they enrolled in special education?

Yes

No

Explain “other” special education

Explain “other” instructional setting

Behavioral Problems At School

Disrespectful

Uncooperative

Unmotivated

Irresponsible

(select all that apply)

School Attendance

Regular

Truant

Please explain circumstances that lead to truant status

Child’s School History

Please list all schools this child has attended for each grade

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

You will be asked to provide their most recent report card during the placement process

Additional Information

What are the child’s interests? What do they like to do for fun?

Are they involved in any extra-curricular activities?

Do they have any nervous habits or unique coping mechanisms?

ex: fingernail biting, hair pulling, thumb sucking or skin picking

Tell us about this child. What would you like to share about them?

Authorization to release information

By checking this box, I approve of sharing all personal information included in this application with Boys and Girls Country of Houston

I agree

Name

First

Last

Signature

Clear

Date

Child’s Information

Additional Child Information

Who is submitting this application?

Legal Guardian Information

Legal Guardian “A” Information (LGA)

Legal Guardian “A” Information (LGA)

(LGA) Employment Information

Legal Guardian “B” Information (LGB)

(LGB) Employment Information

Please complete the following ONLY if the parent’s information is different than the current legal guardians

Parent “A” Information (PA)

Parent “A” Information (PA)

Parent “A” (PA) Employment Information

Parent “B” Information (PB)

Parent “B” Information (PB)

Parent “B” (PB) Employment Information

Income / Financial Benefits Child Receives

Child’s Behavior

Child’s Mental Health

Child’s Background

Child’s Birth Information

Child’s Development

Child’s Medical History

Child’s Immunizations

You will be asked to provide their immunization records during placement process

Child’s General Health

Child’s Medication History

Child’s Health Insurance

Health Insurance Information

Biological Family Medical History

Child’s Education

Child’s School History

You will be asked to provide their most recent report card during the placement process

Additional Information

Authorization to release information

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