Step 1 of 8 12% The information you provide is very important. Please answer all questions. If information is unknown or unavailable, every effort should be made to obtain it. This record will become an important tool to aid us in working with the child and their family.Person Completing the ApplicationDate* MM slash DD slash YYYY Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*Email* Relationship to Child* Child Seeking AdmissionName of Child* First Last Name Child Prefers to be Called* Age* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*Birthdate* MM slash DD slash YYYY Birthplace* Sex* Male Female School Grade* School Name and City* Child Seeking Admission (continue)Who has legal custody?* First Last Relationship* First Last Relationship Who does the child live with?* First Last Relationship* Is the child a U.S. Citizen?* Yes No Is the child adopted?* Yes No Why are you seeking placement at STCH Ministries?*Does the child have a history of involvement with Juvenile Probation System?* Yes No Number of referrals to juvenile authorities: Number of adjudications: Past/Current Offenses:Has CPS been involved in the family situation?* Yes No Worker's Name First Last City Phone NumberNumber of foster home placements* Number of failed adoption placements* Details of All Out-of-Home PlacementsEmergency shelters, detention centers, relatives, hospitals, residential treatment centers foster homes and group homes.Name of Facility or Living Arrangement Date Placed MM slash DD slash YYYY Date Placement Ended MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person First Last Reason placement ended Do you have more facilities or living arrangements to list? Yes No Name of Facility or Living Arrangement Date Placed MM slash DD slash YYYY Date Placement Ended MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person First Last Reason placement ended Do you have more facilities or living arrangements to list? Yes No Name of Facility or Living Arrangement Date Placed MM slash DD slash YYYY Date Placement Ended MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person First Last Reason placement ended Do you have more facilities or living arrangements to list? Yes No Name of Facility or Living Arrangement Date Placed MM slash DD slash YYYY Date Placement Ended MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person First Last Reason placement ended School HistoryPrincipal or Teacher* First Last Address* City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Is the child in the correct grade for their age?* Yes No Has the child been retained?* Yes No If yes, how many times?* How many times has the child been suspended from school?* Explain* How many times has the child been placed in ISS?* Explain How many times has the child been placed in Alternative School?* Explain* Problems at school?* Does the child have Special Education needs?* Yes No If yes, what services are provided?* How many times has the child been truant from school?* Explain* What is the child’s attitude towards school?* Child Information (continue)Child’s Church Membership* Child’s Church Activities?* Does the child have any physical or intellectual disabilities?* Yes No Explain* Does the child have any continuing medical problems?* Yes No Explain* Name of medicine the child currently taking and for what diagnosis:* Has the child ever had psychological testing?* Yes No Date of last appointment:* Who administered the test?* (Please send us a copy of test results, if available.)Has the child ever seen a counselor or therapist?* Yes No Date of last appointment: Counselor or therapist’s name: Agency name: Reason for going: Dates: How long do you feel placement at STCH Ministries Homes for Children will be necessary?*What is the child’s attitude about living at STCH Ministries Homes for Children?* ReferencesList three individuals who know the child.Pastor or an individual you highly respect:* First Last Occupation* Number of years known* Phone*Email* School administrator or teacher:* First Last Occupation* Number of years known* Phone*Email* Adult friend:* First Last Occupation* Number of years known* Phone*Email* Admission QuestionnaireHas the child run away from home or placement?* Yes No Does the child physically fight with peers?* Yes No Does the child physically fight with adults?* Yes No Is the child cruel to animals?* Yes No Does the child talk about killing self?* Yes No Does the child deliberately harm self or attempts suicide?* Yes No Does the child damage or destroy property of others?* Yes No Does the child set fires?* Yes No Does the child have inappropriate sexual behavior?* Yes No Does the child steal at home?* Yes No Does the child steal outside the home?* Yes No Does the child hallucinate?* Yes No Does the child wet himself during the day?* Yes No Does the child wet the bed?* Yes No Does the child soil his bed or clothing?* Yes No Does the child withdraw (does not get involved with others)?* Yes No Does the child get along with other children?* Yes No Does the child prefer playing with older children?* Yes No Does the child act fearful or anxious?* Yes No Does the child have trouble sleeping?* Yes No Is the child sad, unhappy, or depressed?* Yes No Is the child restless, hyperactive, or cannot sit still?* Yes No Does the child have temper tantrums?* Yes No Does the child exhibit sudden mood changes?* Yes No Is the child considered a danger to self?* Yes No Is the child considered a danger to others?* Yes No Does the child have a history of alcohol abuse?* Yes No Does the child have a history of substance abuse?* Yes No Does the child have a history of inhalant abuse?* Yes No Has the child been physically abused?* Yes No Has the child been sexually abused?* Yes No Has the child been emotionally abused?* Yes No Is gang affiliation suspected?* Yes No Has the child ever made a threat with a weapon?* Yes No Does the child have limited intellectual ability?* Yes No Release of Information AuthorizationI hereby release information as stated below for: Child's First Name Child's Last Name I voluntarily and knowingly authorize any individuals, corporations, and/or organizations with pertinent knowledge to release and/or supply information they have concerning the child to South Texas Children's Home Ministries (STCH Ministries). The information to be disclosed and delivered includes but is not limited to the child’s school performance, personal lifestyle, habits, medical records, psychological records, and any other relevant information deemed necessary for the child’s placement at STCH Ministries. I voluntarily and unconditionally release these individuals, corporations, and/or organizations from all liability resulting from the furnishing of this information. I further promise that I will not bring suit against them for providing information regarding this child. A photographic, electronic, or faxed copy of this authorization shall be as valid as the original. This authorization also includes authority to copy any and all such records. This authorization is continuing in nature and is to be given full force and effect to release information on any of the foregoing learned or determined after the date hereof.Signature - Please sign verifying release of information.*Date* MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.
I voluntarily and knowingly authorize any individuals, corporations, and/or organizations with pertinent knowledge to release and/or supply information they have concerning the child to South Texas Children's Home Ministries (STCH Ministries). The information to be disclosed and delivered includes but is not limited to the child’s school performance, personal lifestyle, habits, medical records, psychological records, and any other relevant information deemed necessary for the child’s placement at STCH Ministries.
I voluntarily and unconditionally release these individuals, corporations, and/or organizations from all liability resulting from the furnishing of this information. I further promise that I will not bring suit against them for providing information regarding this child. A photographic, electronic, or faxed copy of this authorization shall be as valid as the original. This authorization also includes authority to copy any and all such records.
This authorization is continuing in nature and is to be given full force and effect to release information on any of the foregoing learned or determined after the date hereof.
