Placement Application

Child for whom this application is made:

Child's Name

First

Middle

Last

Child's Preferred Name (Nickname)

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

Child's Religion

Child's Social Security Number

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

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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