Truth & Change Program

Child Name *

First

Last

Age *

Gender

Male
Female

Parent/Guardian Information

Mother's Name

First

Last

Mother's Age

Mother's Phone

Email

Father's Name

First

Last

Father's Age

Father's Phone

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Who does the child live (reside) with?

Mother
Father
Both

Child's Interest

How much time do you spend with your child outside of school, on learning?

How do you and your child spend this time?( i.e., reading/writing together, assisting with homework)

What, if any, are your concerns with your child’s behavior: at home?

What, if any, are your concerns with your child’s behavior: at school?

What adults are currently consistent in your child’s life? Ie. father mother, grandparents, uncle And what role do they play?

Are there things (skills) that you would like to improve in your child’s behavior? If so what are they?

As a parent, are there skills that you would like to improve on in regards to engaging with your child? If so, what skills?

Emergency Information

Emergency Contact Name *

First

Last

Phone # 1 *

Phone # 2

Email *

Does your child have allergies? *

Yes
No

If answer above is yes, please list.

Preferred Hosiptal

Date

Please download and sign the photo release form. Once signed please attached to application and submit. Note you can also bring the signed copy in with your child.

Click or drag a file to this area to upload.

Photo Release Form for Minors

Signature *

Captcha *

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Parent/Guardian Information

Emergency Information

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