Online Student Application

Part I
A. General Information
Name:
Birth Date:
Soc.Sec#:
Permanent Address
Street:
Apt # :
City:
State:
Zip Code:
Temporary Address
School Name:
Street:
Apt # :
City:
State:
Zip Code:
B. Personal Information
Height:
Weight:
Hair Color:
Eye Color:
Race:
Religion:
Tatoos:
Distinguishing Marks:
Primary Language:
Secondary Language:
Part II
Parent / Guardian Information
Name:
Legal Custody:
Organization:
Relationship to Applicant:
Street:
Apt # :
City:
State:
Zip Code:
Home Phone:
Work Phone:
E-Mail:
Payment Method: Private Payment
Social Service Agency
Third Party Payment
Foundation
Other
If Other Explain:
Part III
Educational Information
School Attending:
Grade Completed:
Present Status: Attending
Non-Attending
Home Schooled
Suspended
Expelled
Other
If Other Explain:
Special Education: Yes No
Learning Disabled: Yes No
ADD / ADHD: Yes No
G.E.D. / Diploma: Yes No
Part IV
A. Behavioral Problems
Check All That Apply:
Verbal Disrespect Physically Aggressive
Lying
Conning
Unmotivated
Other
 Intimidation
Bullying
Stealing
Runaway
Performance
 
If Other Explain:
  What is the primary reason for seeking out of home placement?
B. Physical Health
Prescribed Medication: Yes No
If Yes, List Medications:
Behavior Controlling Medication: Yes No
If Yes, List Medications:
Allergies: Check All That Apply:
Food Bee Stings
Medications Seafood
If Yes, Describe Reaction:
Hereditary and/or Congenital Problems:
Vision: Normal Glasses Unknown
Hearing: Normal Abnormal Unknown
Substance Abuse, Check All That Apply:
Tobacco
Marijuana
Crack
Other
 Alcohol
Cocaine
Inhalants
Heroin
If Other List:
C. Mental Health
Phsychological Problems:
 		Yes No
Emotional Problems:
 		Yes No
Suicide Ideation:
 		Yes No
Self-Desturctive Tendencies:
 		Yes No
Firesetting Tendencies:
 		Yes No
Cruelty to Animals:
 		Yes No
Drug Abuse:
 		Yes No
Alcohol Abuse:
 		Yes No
Part V
Legal Profile
Ever Been Arrested:
 		Yes No
If Yes List Charges:
Has Applicant Ever Been
Adjudicated Delinquent
 		Yes No
On Probation
 		Yes No
Placed in Residential Setting
 		Yes No
Part VI
Social Profile
Applicant's Hobbies :
Sports Desired :
Musical Interests :
Other Interests :
Additional Comments: : Information you feel is important:

Copyright© 2000 Glen Mills Schools
Copying or distributing by any means is strictly prohibited