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UPCOMING EVENTS
Fantasy Football Draft Night 2019
When & Where Wednesday, September 4, 2019 at the NRG Stadium What Join Today’s Harbor for Children, formerly Boys & Girls Harbor, on September 4, 2019 for our 6th Annual Fantasy…
Learn More

Placement Application Form

APPLICATION FOR ADMISSION

APPLICANT’S FULL NAME
DATE OF BIRTH
PLACE OF BIRTH
LAST SCHOOL ATTENDED
CURRENT GRADE
SCHOOL YEAR
SEX
- Male
- Female
RELIGION
PARENT INFORMATION
MOTHER’S NAME
MAIDEN NAME
ADDRESS
PHONE
CITY
STATE
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
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

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