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Truth & Change
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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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
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