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About
- About Us
- Leadership
Giving
Events
Stories
Employment
Contact

Placement Request

This is not an application. After submitting your request for placement, a member of our team will be in touch regarding admission criteria or next steps.

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Child's Information

Name *

First

Last

Date of Birth *

Age

Gender *

Child Address

Address Line 1

Address Line 2

City

State

Zip Code

Current School

Current Grade

Is this child adopted? *

Who is completing this form?

Name *

First

Last

Relationship to Child *

Are you the child's legal guardian? *

Your Email *

Your Phone *

Will you be the primary contact? *

Primary Contact *

First

Last

Primary Email *

Primary Phone

Primary Contact Address

Address Line 1

Address Line 2

City

State

Zip Code

Parent / Legal Guardian

Information is same as primary contact

Same as above

Name *

First

Last

Relationship to Child *

Email *

Phone *

Physical Address

Same as child

Parent / Guardian Address

Address Line 1

Address Line 2

City

State

Zip Code

Additional Parent / Legal Guardian Information

Name

First

Last

Relationship to Child

Phone

Additional Address

Same as above

Parent / Guardian Address

Address Line 1

Address Line 2

City

State

Zip Code

Placement Information

Select all reasons for seeking placement *

Unstable Living Environment
Family Finances
Requires Additional Supervision
Incarcerated Parent/Guardian
Behind In School
Lacks Social Skills
Homeless
Verbal Aggression
Self-Harm
Behavioral Problems
Risk-Taking Behavior
Suicidal Thoughts
Drug Use
Alcohol Use
Physical Aggression
Sexual Inappropriate Behavior
Running Away
Other

Please explain type of physical aggression *

Please explain circumstances surrounding child running away *

Please explain "other" *

Please share why you are seeking placement in your own words: *

Has the child received a diagnosis from a medical doctor or psychiatrist?

Share all diagnosis child has received: *

Is your child aware of our program?

If yes, what are their feelings about our program? *

Please share any additional information you would like us to know about your child:

Get In Touch

18806 Roberts Road, Hockley, TX 77447
info@boysandgirlscountry.org
281-351-4976

Child's Information

Who is completing this form?

Parent / Legal Guardian

Additional Parent / Legal Guardian Information

Placement Information

Get In Touch

Links

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