Placement Application

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Applicant Information

Child for whom this application is made:

Name

First

Middle

Last

Nickname:

Layout

Gender

Race

Eye Color

Age

Religion

Hair Color

Date of Birth

Place of Birth

Social Security Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Who does the child currently live with?

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

Who has legal custody of the child?

Is the child a U.S. Citizen?

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Phone

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

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

What does your child like to do for fun?

Briefly describe your child's strengths:

Who is submitting this application?

Name of person filling out this application

What is your relationship to the child?

Are you submitting this application on behalf of someone else?

Mother's Information

Mother's Name

First

Middle

Last

Mother Maiden Name

Layout

Age

Date of Birth

Social Security Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Phone

Place of Birth

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Highest Level of Education Completed

Religion

Marriage Status

Marital History

Full name of previous spouses. Dates of divorce.

Children born to this parent

Full names, date of birth, father's name, where they currently live

Father's Information

Father's Name

First

Middle

Last

Layout

Age

Date of Birth

Social Security Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Phone

Place of Birth

Layout

Highest Level of Education Completed

Religion

Marriage Status

Marital History

Full name of previous spouses. Dates of divorce.

Children born to this parent

Full names, date of birth, father's name, where they currently live

Parental Employment Information

Mother's Employer

Layout

Job Title

Income

Work Phone

Father's Employer

Layout

Job Title

Income

Work Phone

Income and Benefits the Child Receives

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Social Security

Social Security Amount

Claim Number - Social Security

Child's Background

List all agencies or professionals who have contact with the family (ex: psychiatrist, case worker, counselor)

Name, address, contact information

Is your child physically aggressive?

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

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

Does the child have a diagnosed or suspected health condition or disability?

Does the child have mental health needs that require treatment?

Does the child have a history of drug or alcohol abuse?

Has your child experienced sexual abuse?

Yes
No
Unknown

Has your child experienced emotional abuse?

Yes
No
Unknown

Has your child experienced physical abuse?

Yes
No
Unknown

Has your child experienced neglect?

Yes
No
Unknown

Has your child experienced abandonment?

Yes
No
Unknown

Child's Developmental / Medical History

Birth Information

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

Alcohol or drug abuse, health of mother etc.

Child's Development

Speech Delay or Impairment

Motor Skills Delay (crawling or walking)

Physical Disability or Impairment

Social Skills Disability or Impairment

Emotional Impairment

Immunizations

Are immunizations current?

Upload Immunization Records:

Click or drag a file to this area to upload.

Any known reactions to immunizations?

General Health

Any known allergies to food or medications?

Any serious illnesses?

Any significant injuries?

Any hospitalizations?

Any surgeries?

Has your child has chicken pox?

Medication history for physical, emotional/behavior disorders:

Medication, dosage, length of time used

Is child sick often with minor ailments?

Does child fake illness or complain frequently of ailments?

Any unreasonable fear of doctors or injections?

Please describe any nervous or personal habits the child has:

How is the child's personal hygiene and grooming?

Poor
Good
Great

Any sleep problems or significant factors related to sleeping?

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

How is their overall health?

Poor
Good
Great

Do they have health insurance?

Family Medical History

School Information

School they are currently enrolled at:

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

Current Grade:

Are they enrolled in special education?

Instructional Setting:

Mainstreamed
Homebound
Resource
Self-Contained

School Problems:

Disrespectful
Uncooperative
Umotivated
Irresponsible

School Attendance:

Regular
Truant

Has the child ever been suspended or expelled from school?

Please list all school 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

Please attached most recent report card:

Click or drag a file to this area to upload.

Authorization to release information:

By checking this box, I authorize Boys and Girls Country of Houston to release any medical, social, educational or psychological information concerning my child.

I agree

Save and Resume Later

Placement Application

Applicant Information

Who is submitting this application?

Mother's Information

Father's Information

Parental Employment Information

Income and Benefits the Child Receives

Child's Background

Child's Developmental / Medical History

Birth Information

Child's Development

Immunizations

General Health

Family Medical History

School Information

Please list all school this child has attended for each grade:

Authorization to release information:

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