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Placement Application Form
APPLICATION FOR ADMISSION
If you are looking to place your child at Today's Harbor for Children, the admission process includes completing an application form and a personal interview with both the child and their family to understand and access the child's needs. You will also need to provide: • Copies of any school records • Immunization records • Birth certificate • Social Security card • Physical examination done within the last 30 days • Any additional documents that might be in the best interest of understanding the child's needs
APPLICANT’S FULL NAME
DATE OF BIRTH
Date Format: MM slash DD slash YYYY
PLACE OF BIRTH
LAST SCHOOL ATTENDED
CURRENT GRADE
SCHOOL YEAR
2010
2011
2012
SEX
Male
Female
RELIGION
PARENT INFORMATION
MOTHER’S NAME
MAIDEN NAME
ADDRESS
PHONE
CITY
STATE
CA
TX
FL
ZIP
PARENT INFORMATION CONTINUED
EMPLOYED
Yes
No
EMPLOYER’S NAME
EMPLOYER’S ADDRESS
SOCIAL SECURITY NO
MONTHLY TAKE HOME SALARY
HOSPITAL INSURANCE COVERAGE
Yes
No
COMPANY
GROUP NO
POLICY NO
FATHER’S NAME
MAIDEN NAME
ADDRESS
PHONE
CITY
STATE
CA
TX
FL
ZIP
PARENT INFORMATION CONTINUED
EMPLOYED
Yes
No
EMPLOYER’S NAME
EMPLOYER’S ADDRESS
SOCIAL SECURITY NO
MONTHLY TAKE HOME SALARY
HOSPITAL INSURANCE COVERAGE
Yes
No
COMPANY
GROUP NO
POLICY NO
HAS THE APPLICANT EVER BEEN PHYSICALLY, SEXUALLY, OR EMOTIONALLY ABUSE?
Yes
No
IF YES, WHICH ONE? PLEASE DESCRIBE.
HAS THE APPLICANT EVER BEEN CONVICTED OF A CRIME?
Yes
No
IF YES, PLEASE DESCRIBE.
HAS THE APPLICANT EVER SEEN A PSYCHOLOGIST OR PSYCHIATRIST??
Yes
No
IF YES, WHICH ONE? PLEASE GIVE NAME, ADDRESS AND PHONE.
REASON FOR SEEING THIS PROFESSIONAL.
MEDICAL INFORMATION
PLEASE LIST ANY KNOWN ALLERGIES.
NAME OF THE PERSON WHO IS MANAGING CONSERVATOR (CUSTODY)
ADDRESS OF PERSON WHO IS MANAGING CONSERVATOR (CUSTODY)
LIST BROTHERS AND SISTERS LIVING AT HOME(INCLUDE NAME, AGE, BIRTHDATE, ADDRESS, MARITAL STATUS)
LIST THE NAMES, ADDRESSES AND PHONE OF ANY OTHER INVOLVED ADULTS OR AGENCIES.(INCLUDE NAME, ADDRESS, PHONE)
SCHOOL INFORMATION
FORMER SCHOOLS (INCLUDE SCHOOL NAME, ADDRESS, GRADE)
WAS THE APPLICANT IN SPECIAL EDUCATION?
Yes
No
IF SO, HOW WAS THE STUDENT CLASSIFIED?
Learning Disabled
Emotionally Disturbed
Other
IF OTHER, WHICH ONE?
SCHOOL INFORMATION CONTINUED
HAS THE APPLICANT FAILED ANY GRADES?
Yes
No
IF YES, WHAT GRADES?
PLEASE DESCRIBE THE APPLICANT’S SCHOOL BEHAVIOR.
PLEASE DESCRIBE FAMILY RELATIONSHIPS.
PLEASE LIST THE REASONS PLACEMENT IS BEING SOUGHT
IS THE PARENT DIVORCED, MARRIED, SINGLE?
HAS THE APPLICANT EVER LIVED AWAY FROM THE PARENT PREVIOUSLY?
Yes
No
IF YES, WHERE? (PLEASE INCLUDE NAME, ADDRESS, DATE)
INFORMATION CONTINUED
REASON FOR LEAVING?
HAS THE APPLICANT ABUSED DRUGS?
Yes
No
IF YES. PLEASE DESCRIBE
PLEASE DESCRIBE THE APPLICANT’S BEHAVIOR
PLEASE DESCRIBE THE APPLICANT’S INTERESTS
PLEASE DESCRIBE THE APPLICANT’S PERSONALITY
GOALS (CONTINUED)
APPLICATION COMPLETED BY
ADDRESS
RELATIONSHIP TO CHILD
