Placement Application

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- Step 1 of 18

Child's Information

Child for whom this application is made:

Name *

First

Middle

Last

Nickname:

Gender *

Age *

Race *

Religion

Eye Color *

Hair Color *

Date of Birth *

Place of Birth *

Is the child a U.S. Citizen? *

Social Security Number *

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Child's Email *

No email address for child

No email address

Child's Phone *

No phone number for child

No phone number

Who does the 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? *

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Who is submitting this application?

Name *

First

Middle

Last

What is your relationship to the child? *

Are you submitting this application on behalf of someone else? *

If yes, who? *

who are you submitting this application on behalf of

Email *

Phone *

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

Are you the legal guardian of this child? *

Legal Guardian Information (A)

Same as submitter

Same as above

Legal Guardian Name *

First

Middle

Last

Phone

Date of Birth

Place of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Marriage Status

Marital History

Full name of previous spouses. Dates of divorce.

Children born to this parent

Full names, date of birth, where they currently live

Highest Level of Education Completed

Employment Information

Employer

Job Title

Income

Work Phone

Previous Name (if applicable)

First

Middle

Last

Age

Social Security Number

Religion

Legal Guardian Information (B)

Legal Guardian Name

First

Middle

Last

Phone

Date of Birth

Place of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Marriage Status

Marital History

Full name of previous spouses. Dates of divorce.

Children born to this parent

Full names, date of birth, where they currently live

Highest Level of Education Completed

Employment Information

Employer

Job Title

Income

Work Phone

Previous Name (if applicable)

First

Middle

Last

Age

Social Security Number

Religion

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Please complete this section if the parent's information is different than the legal guardians

Parent Information (A)

Same As Guardian (A)

Same As Guardian (A)

Parent Name *

First

Middle

Last

Phone

Date of Birth

Place of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Marriage Status

Marital History

Full name of previous spouses. Dates of divorce.

Children born to this parent

Full names, date of birth, where they currently live

Highest Level of Education Completed

Employment Information

Employer

Job Title

Income

Work Phone

Previous Name (if applicable)

First

Middle

Last

Age

Social Security Number

Religion

Parent Information (B)

Same As Guardian (B)

Same As Guardian (B)

Parent Name *

First

Middle

Last

Phone

Date of Birth

Place of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Marriage Status

Marital History

Full name of previous spouses. Dates of divorce.

Children born to this parent

Full names, date of birth, where they currently live

Highest Level of Education Completed

Employment Information

Employer

Job Title

Income

Work Phone

Previous Name (if applicable)

First

Middle

Last

Age

Social Security Number

Religion

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Income and Financial Benefits this Child Receives

Social Security *

Child Support *

TANF *

Other Income *

Other Income Details *

Describe other types of income for the child

Social Security Claim Number

Child Support Amount

TANF Amount

Other Income Amount

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Child's Behavior

Is this child physically aggressive? *

Please explain physically aggressive behavior *

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

Please explain self-harm behavior in detail *

Does this child have a history of alcohol abuse? *

Please explain alcohol abuse behavior *

Does this child have a history of smoking or vaping? *

Please explain smoking or vaping behavior (ex: cigarettes, vape pens, vaporizers) *

Does this child have a history of drug abuse? *

Please explain drug abuse behavior (ex: marijuana, opioids) *

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Child's Mental Health

Has this child ever received a mental health diagnosis? *

Please list mental health diagnosis *

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

Please share details of residential or psychiatric treatment *

Does this child have mental health needs that require treatment? *

Please explain mental health needs *

List all professional services who have contact with the family (ex: psychiatrist, counselor, doctor)

Service, Name, Contact Information

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