Little Application
Questions marked by * are required.
1.
Child's name: *
2.
Gender: *
3.
Pronoun:
4.
Date of Birth: *
5.
Age: *
-
6
7
8
9
10
11
12
13
14
6.
Languages Spoken: *
7.
Ethnicity:
8.
Street Address: *
9.
City / State / Zip: *
10.
Home Phone: *
11.
Cell Phone:
12.
Child's Parent/Guardian 1: *
Mother
Father
Grandparent
Foster Parent
Other
13.
Parent/Guardian's Name (and address, if different than the above): *
14.
Parent/Guardian's Date of Birth: *
15.
Parent/Guardian's Email:
16.
Languages Spoken (Parent/Guardian): *
17.
Parent/Guardian's Ethnicity:
18.
Parent/Guardian's Present Marital Status: *
Single
Married
Divorced
Widowed
19.
Child's Second Parent/Guardian (if applies):
Mother
Father
Grandparent
Foster Parent
Other
20.
Parent/Guardian 2's Name (and address, if different than the above):
21.
Parent/Guardian 2's Date of Birth:
22.
Parent/Guardian 2's Home Phone:
23.
Parent/Guardian 2's Cell Phone:
24.
Parent/Guardian 2's Email:
25.
Languages Spoken (Parent/Guardian 2):
26.
Parent/Guardian 2's Ethnicity:
27.
Parent/Guardian 2's Present Marital Status:
Single
Married
Divorced
Widowed
28.
Have you spoken to the non-custodial parent about this application?
Yes
No
Plan to
29.
Please list all persons living in your home, both children and adults (Name / Sex / Age / Relationship to Child): *
30.
Counselor / Therapist Phone:
31.
Has your child ever been in any kind of institution? If so, when and why:
32.
How did you hear about this program? or who referred you? *